CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2503 -    ..
2504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
2505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250501 - Follow up ref SDS P4 0000. ref SDS P2 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250503 - No diffuculty swallowing this cycle with LESV dilated to 18 mm 6 weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250504 - ago on 180227. ref SDS 0 VV6N  No difficulty with digestion using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250505 - medication protocol, reviewed during meeting with Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250506 - 180124. ref SDS 0 PD5F  Signed blank consent for the procedure today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250507 - on assurance that stroke symptoms following prior EGD on 160617, with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250508 - mild recurrence on 161213, would not occur.  Doctor Lee was pressed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250509 - for time today, so deferred agenda issues to post-procedure meeting in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250510 - 3 weeks. ref SDS 0 KT9M  EGD dilation procedure went smoothly, with no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250511 - reports of difficulties. ref SDS 0 7V6I  Gastroscope in and out took                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250512 - 16 minutes, ref SDS 0 UT4N, and versed sedation medication required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250513 - only 3 ML, well below 6 ML that caused prior symptoms. ref SDS 0 CR4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250514 - Post procedure Doctor Lee reported good results with LESV contracting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250515 - to only 16.5 mm, so he was able to dilate LESV to 19 mm, achieving                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250516 - goal previously reached 6 procedures (a year) ago. ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250517 - Ulceration improved over the past 8 weeks, which enabled the doctor to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250518 - dilate LESV needed for better swallowing. ref SDS 0 RZ3G  Continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250519 - improvement in ulceration and LESV dilation shows good response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250520 - treatment with prescribed medications. ref SDS 0 JK6N  Scheduled next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250521 - EGD dilation in 4 - 6 weeks, and consult in 3 weeks to review pending                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250522 - issues.  This will require another overbook, which the doctor will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250523 - work out with Paul tomorrow. ref SDS 0 ES4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250525 -             ..
250526 -            [On 180418 0932 Paul called from GI Clinic at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250527 -            Center in Sacraento; he will consult with Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250528 -            scheduling consult in 3 weeks, and next EGD dilation in 6 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250529 -            8 weeks. ref SDS P6 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250531 -             ..
250532 -            [On 180423 1017 letter to Jessica requesting she notify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250533 -            Doctor Lee to call about scheduling meeting and next EGD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250534 -            ref SDS P7 OA3W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250536 -             ..
250537 -            [On 180425 1130 Kathy met with Jessica and at that time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250538 -            Jessica scheduled next EGD on 180605 0800, she scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250539 -            review meeting 6 weeks later on 180711, the next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250540 -            dilation was scheduled 2 days later on 180713, and review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250541 -            meeting was scheduled 6 days later on 180719.   The review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250542 -            meeting ordered by Doctor Lee for 3 weeks after recent EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250543 -            on 180417, is still not scheduled. ref SDS P8 9O6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250547 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250548 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250550 -  ..
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 111201 0928 seems to be 10% increase in blood pressure the past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251120 - month, ref SDS 83 ZM5H, beginning on 111030, shown by case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251121 - 101010 0744. ref SDS 57 UT6K  Case study reports Omeprazole paused on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251122 - 111201. ref SDS 57 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251124 -  ..
251125 - On 120322 1030 notified Doctor Lee during meeting at VA changed dose                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251126 - for Omeprazole to reduce sudden increase from low to high blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251127 - pressure. ref SDS 85 UH5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251129 -  ..
251130 - On 120322 1030 EGD dilation procedure - swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251131 - increased without triamcinolone steriod injections on prior 3 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251132 - cycle. ref SDS 85 UI9H  LESV dilated from 16.5 - 18 mm. ref SDS 85                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251133 - 516N  Triamcinolone injections to resist contraction of LESV was not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251134 - performed. ref SDS 85 5179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251136 -  ..
251137 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251138 - business unit; reported patient history. ref SDS 88 RG9K  Scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251139 - EGD and dilation procedure for 1300; returned and performed procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251140 - ref SDS 88 TB4J; dilated from 15 mm to 18 mm. ref SDS 88 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251141 - Swallowing and vomitting problems increased after omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251142 - triamcinolone steriod injections to resist contraction of LESV after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251143 - dilation, ref SDS 88 TZ4M; therefore, injections were resumed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251144 - complement dilation to enable and maintain effective swallowing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251145 - ref SDS 88 R87N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251147 -  ..
251148 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251149 - improvement recovering from acalasia, LESV contracted only slightly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251150 - from 18 mm down to 15 mm. ref SDS 96 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251152 -  ..
251153 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251154 - remained at 18 MM, ref SDS A1 CO5N, same as dialated 4 months earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251155 - on 130110 0900. ref SDS 96 Q333  Report CT test on 130117, shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251156 - esophagus fully recovered from severe distortions caused by achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251157 - 8 years earlier. ref SDS A1 MT6F  Doctor Lee injected steriod again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251158 - maintain swallowing. ref SDS A1 F38G  Prescribed reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251159 - to 1 pill per day. ref SDS A1 R74M  Scheduled next EDG dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251160 - months, instead of 3. ref SDS A1 6P6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251162 -  ..
251163 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251164 - to 18 mm. ref SDS A7 CO5N  Triamcinolone steriod injected again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251165 - maintain improved swallowing. ref SDS A7 I167  Omeprazole medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251166 - maintained 20 mg taken morning and evening for 1 month, then reduce to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251167 - 20 mg once per day. ref SDS A7 R74M  Biopsies taken. ref SDS A7 3N8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251169 -  ..
251170 - On 131121 1604 ordered refill of Omeprazole to aid digestion.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251171 - is 1 refill remaining. ref SDS A8 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251173 -  ..
251174 - On 131205 1443 received order for Omeprazole prescription placed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251175 - 131121. ref SDS A9 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251177 -  ..
251178 - On 140318 1043 received letter cancelling meeting scheduled for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251179 - EGD/Dilation procedure on 140425 1000, ref SDS B2 935L; a second                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251180 - letter scheduled prodedure on 140509 0900. ref SDS B2 5D7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251182 -  ..
251183 - On 140401 1659 ordered refill Omeprazole; none are remaining; need                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251184 - Doctor Lee to order new prescription to increase refills. ref SDS B3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251185 - 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251187 -  ..
251188 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251189 - center in Sacramento, Mather. ref SDS B5 K37G  Pre-op preperation went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251190 - well - IV setup on first stick. ref SDS B5 EP75  Doctor ordered refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251191 - for Omeprazole. ref SDS B5 AW5O  Doctor patient partnership continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251192 - to progress with doctor reading up on patient history to be prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251193 - for effective meeting. ref SDS B5 ZZ6J  Doctor Lee recalled today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251194 - having made timely referral for having heart surgery, enabling patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251195 - to recover and Half Dome 4 years later. ref SDS B5 0N6I  Reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251196 - swallowing and vomitting problems reduced past 6 months with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251197 - triamcinolone steriod injections to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251198 - ref SDS B5 VV6N  Doctor Lee dilated LESV contracted to only 16.5 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251199 - over past 6 months with triamcinolone steriod injections to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251200 - contraction; he dilated LESV back to 18 MMy, ref SDS B5 5H5J, scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251201 - next EGD dilation in 6 months since this worked well the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251202 - with triamcinolone steriod injections. ref SDS B5 549I  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251203 - explained that since there was no tearing of LESV during procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251204 - today, triamcinolone steriod was not injected into LESV to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251205 - contraction. ref SDS B5 I167  Progress notes report small tearing of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251206 - LESV during dilation procedure. ref SDS B5 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251208 -  ..
251209 - On 140718 1017 planning for notifying VA to update current fill date                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251210 - for Omeprazole. ref SDS B9 U88L  Kathy visited VA in Sacramento, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251211 - requested changing refill date for Omeprazole to 140718. ref SDS B9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251212 - OL5K  VA representative called customer, and said Doctor Lee would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251213 - call back later that day to consider action on updating scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251214 - refill date of Omeprazole to 140718. ref SDS B9 U76M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251216 -  ..
251217 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251218 - triamcinolone injection soonest, if cancellation occurs; but, not an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251219 - emergency, ref SDS C1 W83K, based on history rising vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251220 - swallowing problems, shown in patient history case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251221 - beginning 140712. ref SDS 84 4E4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251223 -  ..
251224 - On 140819 0800 during meeting at VA Primary Care Clinic in Martinez,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251225 - Doctor Sandhu indicated Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251226 - will be notified about rising achalasia symptoms for consideration to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251227 - advance EGD dilation procedure. ref SDS C2 EX78                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251229 -  ..
251230 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251231 - with Lapria again, who advised that the VA responded in a letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251232 - 141001, to the letter on 140810, and further scheduled a meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251233 - Doctor Lee on 141121 1530. ref SDS C3 QJ5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251235 -  ..
251236 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251237 - Sacramento Medical Center on 141107 0800, for next EGD dilation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251238 - ref SDS C4 K37G  Submit record showing normal swallowing occurs longer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251239 - with triamcinolone steriod injection to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251240 - ref SDS C4 3U97  Request schedule next EGD dilation in 4 months, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251241 - if LESV does not contract, then schedule following EGD dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251242 - months. ref SDS C4 3U66  Notified results of Half Dome hike.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251243 - ref SDS C4 3U6Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251245 -  ..
251246 - On 141107 0800 EGD dilation procedure - setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251247 - sedation required 3 sticks. ref SDS C5 5W5I  Meeting Doctor Lee guided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251248 - by agenda facilitated collaboration through doctor patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251249 - partnership. ref SDS C5 VV6N  Doctor explained increased difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251250 - swallowing due to experiment omitting triamcinalone steriod injection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251251 - on prior procedure, ref SDS C5 4U8I, shown by LESV contracting back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251252 - from 15 mm. ref SDS C5 T55I  Progress Notes report finding ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251253 - and hiatal hernia. ref SDS C5 MG6N  Photographs seem to show                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251254 - significantly different condition of fundoplication from a year                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251255 - earlier. ref SDS C5 I74I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251257 -  ..
251258 - On 150319 0800 meeting Doctor Lee in GI Clinic VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251259 - Sacramento report swallowing improved with triamcinalone steriod                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251260 - injections on 141107 EGD dilation procedure. ref SDS D1 0M6I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251261 - Lee advised that increased orange juice consumption aids digestion,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251262 - and presents no health risks. ref SDS D1 YF5M  Scheduled next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251263 - dilation procedure on 150421 1300. ref SDS D1 PS4O  Fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251264 - failure increases acid burn that caused ulceration with hiatal hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251265 - with increased recurrance achalasia. ref SDS D1 O56O  Doctor Lee will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251266 - make referral to Doctor Stewart at General Surgery VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251267 - in San Francisco for consideration of "redo" fundaplicaiton.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251268 - ref SDS D1 JQ5J  Doctor Lee completed Progress Notes for EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251269 - on 141107. ref SDS D1 PS53  Doctor Lee will recommend Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251270 - order CT test to evaluate recurrance achalasia due to failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251271 - fundoplication. ref SDS D1 TH5M  This test can include coronary CTA to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251272 - evaluate regression atherosclerosis. ref SDS D1 GB56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251274 -  ..
251275 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251276 - the next day on 150421 1300 for EGD dilation. ref SDS D3 0M6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251278 -  ..
251279 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251280 - (Mather). ref SDS D4 K37G  No difficulties setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251281 - sedation. ref SDS D4 5W5I  Reported pain level 2 right knee MCL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251282 - ref SDS D4 LO9K  Doctor Lee advised referral to San Francisco will be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251283 - filed after EDG dilation procedure (this day) to evaluate loosening                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251284 - fundoplication. ref SDS D4 DZ4I  Patient reported difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251285 - swallowing this cycle did not occur until 4 weeks or so, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251286 - triamcinalone steriod was injected during prior procedure on 141107,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251287 - ref SDS D4 P55L, and shown by EGD dilation LESV from 16.5 mm back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251288 - 18 mm. ref SDS D4 HU42  Progress Notes report findings of hiatal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251289 - hernia. ref SDS D4 QD6O  Impression today that ulceration has subsided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251290 - to mere errosions seems promising. ref SDS D4 PXXY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251292 -  ..
251293 - On 150514 0130 letter to Doctor Lee requests file Progress Notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251294 - EGD Dilation today, and make referral to Doctor Stewart, to prepare                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251295 - for meeting with Doctor Lee scheduled on 150521. ref SDS D6 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251297 -  ..
251298 - On 150521 0800 meeting with Doctor Lee at VAMC in Sacramento -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251299 - concensus uncharacteristic vomitting after recent EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251300 - procedure on 150421, due to patient not eating slowly with small bites                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251301 - and drinking liquids frequently, especially when eating meat products                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251302 - that have high viscocity with esophageal tissue, and so tends to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251303 - stick, causing vomitting. ref SDS D8 WT9L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251305 -  ..
251306 - On 150526 1300 meeting with Doctor Stewart Chief General Surgery VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251307 - Medical Center San Francisco, review record indicating ulceration LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251308 - caused by reflux backwash into esophagus. ref SDS D9 3E4I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251309 - Stewart explained redo Dor Fundoplication required for "repairing"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251310 - original surgery, presents high risk of collateral damage. ref SDS D9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251311 - GT5G  Considered increase dose Omeprazole (PPI) since ad hoc                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251312 - experience occasionally taking 3 and sometimes 4 pills instead of only                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251313 - 1 pill per day seemed to reduce reflux based on examination showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251314 - ulceration of LESV declined; this would avoid need to redo Dor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251315 - Fundoplication. ref SDS D9 5Y4I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251317 -  ..
251318 - On 150616 1624 received photographs on CD in word.docx file from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251319 - Phillip in ROI Department at VA MC in Sacramento (Mather) showing Dor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251320 - fundoplication in tact on 131115, beginning to unravel on 140507,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251321 - further unraveled on 141107, and unraveled on 150421. ref SDS E2 XW6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251323 -  ..
251324 - On 150623 1300 during follow up meeting, Doctor Stewart discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251325 - again increasing Omeprazole PPI to resolve ulceration of LESV rather                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251326 - than risk difficult surgery to redo Dor fundoplication, and she                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251327 - ordered prescription for H2 blocker to supplement Omeprazole PPI.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251328 - ref SDS E3 WW5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251330 -  ..
251331 - On 150624 0924 letter notified Doctor Lee of work plan to try                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251332 - controlling ulceration of LESV by increasing PPI with Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251333 - rather than chance performing high risk surgery to repair Dor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251334 - fundoplication, and that Doctor Stewart ordered H2 Blocker for Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251335 - Lee to consider supplementing PPI to control acid reflux. ref SDS E4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251336 - OP91                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251338 -  ..
251339 - On 150624 0924 at 1344 Doctor Lee called and will order new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251340 - prescription for PPI increasing Omeprazole from 20 mg twice per day to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251341 - 40 mg twice per day. ref SDS E4 L861                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251343 -  ..
251344 - On 150925 0336 request switch back to Omeprazole 20 mg twice per day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251345 - in order to reduce severe side effects of dehydration from frequent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251346 - urination causing scaling, peeling, bleeding feet; lower dose                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251347 - Omeprazole enables hiking to raise HDL required to regress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251348 - atherosclerosis plaques, thereby lowering risks of CVD and CAD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251349 - ref SDS E6 5G8T  As a result, Pharmacy VA Medical Center San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251350 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS E6 FK66                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251352 -  ..
251353 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251354 - 0800. ref SDS E6 SR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251356 -  ..
251357 - On 151002 1820 Doctor Lee returned call; will order Omeprazole 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251358 - prescription sufficient until next EGD Dilation procedure on 151204,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251359 - and complimenting prescription entered on 150925 for only 1 month.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251360 - ref SDS E7 NV5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251362 -  ..
251363 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251364 - prescription. ref SDS D5 0C5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251366 -  ..
251367 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251368 - (Mather); initial administration went well. ref SDS F4 GD4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251369 - Preparation for the procedure was professional; no difficulties                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251370 - setting IV for conscious sedation today. ref SDS F4 544G  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251371 - reported not receiving letter with agenda for the meeting today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251372 - submitted on 151201. ref SDS F4 VV6N  Patient difficulty swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251373 - occurred after 5 months, because triamcinalone steriod injected prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251374 - procedure on 150421.  Swallowing difficulty/vomiting increased over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251375 - the next 3 months indicates dilate LESV 18 mm and doing EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251376 - in 6 rather than 8 months. ref SDS F4 P55L  Asked about Baking Soda to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251377 - clear throat in order to avoid vomitting, and prevent ulceration LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251378 - alternative to Omeprazole in order to avoid side effects causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251379 - dehydration. ref SDS F4 G53K  Performing EGD dilation procedure went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251380 - smoothly, with no difficulties. ref SDS F4 7V6I  Post procedure Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251381 - Lee reported LESV contracted to 10 mm, the worst results in patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251382 - history, indicating 2 month delay performing procedure this cycle was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251383 - harmful. ref SDS F4 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251385 -  ..
251386 - On 151210 meeting Doctor Lee after EGD on 151204, changed prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251387 - of Omeprazole (PPI) to 20 mg every other day to eliminate or reduce                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251388 - dehydration from frequent urination, and in order for feet to recover                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251389 - from peeling, cracking, bleeding so that hiking can be performed at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251390 - level of 300 miles per month required to raise HDL > 60, required to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251391 - regress athersclerosis. ref SDS F7 J56O  Doctor prescribed adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251392 - Famotidine an H2 blocker taken once a day to compliment Omeprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251393 - ref SDS F7 YL3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251395 -  ..
251396 - On 160325 0900 Diffuculty swallowing this cycle began about 1 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251397 - after prior EGD dilation on 151204. ref SDS G8 P55L  Reported using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251398 - baking soda to relieve reflux that prevents ulceration LESV; this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251399 - reduced Omeprazole in order to avoid dehydration. ref SDS G8 Z84H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251400 - Progress Notes report there is no longer any erosive esophagitis and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251401 - there is no evidence of mass effect, which implies better acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251402 - suppression compared to previous examination December 2015.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251403 - ref SDS G8 PXXY  EGD dilation procedure went smoothly, with no reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251404 - of difficulties. ref SDS G8 7V6I  Post procedure Doctor Lee reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251405 - LESV contracted to 9.5 mm, the smallest in patient history, indicating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251406 - 2 month delay to 8 months performing procedure in December causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251407 - continual injury. ref SDS G8 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251409 -  ..
251410 - On 161128 1119 called VA GI Clinic in Sacramento; LaPreia said meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251411 - Doctor Lee scheduled for 161214, has been changed to the next day on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251412 - 161215 1200. ref SDS K2 OZ9G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251414 -  ..
251415 - On 161205 0846 anonomous flowers and chocolates sent wishing GI staff                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251416 - Merry Christmas and Happy New Year for doing terrific work.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251417 - ref SDS K5 FS5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251418 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251419 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251420 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251421 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251422 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251424 -  ..
2515 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2516 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2517 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2518 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251801 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251802 - GI Department VA Sacramento Medical Center Administration EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251803 - 
251804 - Follow up ref SDS P4 NU8L, ref SDS P2 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251806 - EGD treatment today, was scheduled by LaPria, during meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251807 - Doctor Lee on 180307 1045 at 1228. ref SDS P5 K44I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251809 -  ..
251810 - At that time, there was not enough time to also scheduled review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251811 - meeting. ref SDS P5 E44J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251813 -  ..
251814 - Performing EGD dilation 8 weeks after prior procedure on 180227 0800,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251815 - ref SDS P4 NU8L, represents continuing recovery from severe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251816 - contraction LESV 6 mm, worst condition in patient history, found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251817 - during procedure on 161122, ref SDS K1 0001, and which prevented                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251818 - dilation above 12 mm. ref SDS K1 433O  The 8-week interval may have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251819 - been too long, since beginning about 2 weeks ago was feeling LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251820 - shutting down, with difficulty swallowing, reported on 171014, in case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251821 - study on 160101 0700. ref SDS G1 YRTP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251823 -  ..
251824 - Applied pre-proc requirements for NPO after midnight, from letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251825 - 101015 1547. ref SDS 59 4J9L  Last food was at......                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251827 -  ..
251828 - Drove to Sacramento yesterday afternoon.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251830 -  ..
251831 - At 0720, checked into GI Department at the customer counter..                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251832 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251833 -                         800-382-8387                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251834 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251835 -                         916 843 7000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251837 -  ..
251838 - Kathy cell phone for designated driver...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251842 -  ..
251843 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251844 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251845 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251846 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251847 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251848 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251849 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251851 -  ..
2519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2521 - 0725                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252201 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252202 - 
252203 - Follow up ref SDS P4 EP75, ref SDS P2 EP75.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252204 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252205 - No objections nor concerns today, as occurred previously on 161115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252206 - 0800, ref SDS J7 WA5I, and again last week on 161130 1038. ref SDS K3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252207 - EP75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252209 -  ..
252210 - Rose did vitals today, prior to procedure in a small office just off                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252211 - the lobby, and not in the treatment preparation area, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252212 - 120925 0900. ref SDS 88 PT5P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252214 -  ..
252215 - She wore a surgeon's mask to protect against transmitted diseases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252216 - from patients.  Rose seemed a little wobbly today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252218 -  ..
252219 - Vitals found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252220 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252221 -            Weight.................. 179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252222 -            BP...................... 128 59                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252223 -            HR (pulse).............. 62                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252224 -            Oxygen.................. 99                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252225 -            Temp.................... 97                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252227 -  ..
252228 - Rose asked questions on patient history to verify ready for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252229 - procedure, e.g., no allergies, and NPO after midnight to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252230 - conflicts with anesthesia; no health problems, e.g., no diabetes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252231 - alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252232 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252234 -  ..
2523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2525 - 0742                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252601 - Followed Hazel into the GI Prep area.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252603 -  ..
252604 - Ann configured on gurney and connected equipment to monitor vitals                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252605 - during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252607 -  ..
252608 - Frank set catheter IV for sedation.  He was not successful on 1st                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252609 - stick; it was pain level 6.  Veins develop adhesions (scar tissue) and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252610 - take time to heal, and prevent blood flow into the IV needle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252611 - Denise consulted.  Frank moved the needle penetration down slightly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252612 - and this 2nd stick was successful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252614 -  ..
252615 - Case study on sticks required to set catheter is reported on 110429                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252616 - 1230. ref SDS 76 UO3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252618 -  ..
252619 - Ann went through patient identification and medical profile filling                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252620 - out forms on the computer based on prior information 7 weeks ago on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252621 - 180109 0800. ref SDS P2 6Y8K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252622 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252624 -  ..
252625 - She asked about pain?  Reported level 0.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252626 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252627 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252628 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252630 -  ..
2527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2529 - 0905                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253001 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253002 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253003 - 
253004 - Follow up ref SDS P4 KT9M, ref SDS P2 KT9M.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253006 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253007 - procedure today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253009 -  ..
253010 - Noted that signature is entered on completely black screen, required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253011 - without reading online documents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253013 -  ..
253014 - Advised that signature is based on following understandings...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253016 -  ..
253017 - Agenda Meeting Doctor Lee...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253018 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253019 -    1.  Orthopedic issues - had 3rd PRP injection treatment for both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253020 -        feet and both knees last Friday, on 180105 1630, ref SDS P0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253021 -        0001, which was reported previously to Doctor Lee during prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253022 -        EGD procedure on 180109 0800. ref SDS P2 GX4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253023 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253025 -         ..
253026 -    2.  Internist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253027 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253028 -        Trying to avoid pain medication.  About 2 hours after hikes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253029 -        legs can be very painful, especially walking downstairs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253031 -         ..
253032 -        About 4+ hours after hiking rest of body feels "bad".                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253034 -         ..
253035 -        Occasionally take hydrocodone before hiking to suppress pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253036 -        in feet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253038 -         ..
253039 -        Took hydrocodone after 12 mile hike starting at 0400 through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253040 -        Golden Gate Park, preparing for lab at 0730 at VAMCSF.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253042 -         ..
253043 -        Doctor Tucker prescribed avoiding NSAIDs, e.g., ibuprofen,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253044 -        naproxen, because these drugs prevent production of collagen,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253045 -        stimulated by PRP treatment to regenrate ligaments and tendons,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253046 -        cartilage, reported on 170726 1600. ref SDS N7 656F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253048 -         ..
253049 -        Naproxen most effective pain relief, after hydrocodone, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253050 -        pills cause ulceration LESV.  Can Doctor Lee order liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253051 -        naproxen to prevent this problem?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253052 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253054 -         ..
253055 -    3.  Voice very scratchy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253056 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253057 -        Primary care provider, Lauren Rettberg wrote letter reporting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253058 -        she found patient voice difficult to follow.  She wants GI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253059 -        doctor to investigate during examination for EGD on 180417.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253060 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253061 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253063 -         ..
253064 -    4.  Pantoprazole - effective taking 1 40 mg pill per day, beginning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253065 -        on 170615, shown in case study on 160101 0700, ref SDS G1 YS7H,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253066 -        and with Famotidine 2 40 mg pills twice per day, beginning on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253067 -        170725, shown in case study on 160101 0700, ref SDS G1 1R9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253069 -         ..
253070 -        Full medication regimen reported to Doctor Lee during meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253071 -        at VA Medical Center in Sacramento on 180124 1130. ref SDS P3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253072 -        5I5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253074 -         ..
253075 -        Assess today, toward maintaining reduced dose, or increase                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253076 -        dose on findings of ulceration LESV recurrance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253078 -         ..
253079 -        Feet seem recovered from dehydration, previously caused by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253080 -        high dose Pantoprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253082 -         ..
253083 -        Blood pressure seems trending down after reducing Pantoprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253084 -        and increasing hiking, and further reducing Mylanta and calcium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253085 -        carbonate (Tums).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253087 -         ..
253088 -        Study on proton pump inhibitor (PPI) - Pantoprazole and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253089 -        Omeprazole - requested by Doctor Lee on 170301 1200,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253090 -        ref SDS M4 A89F, was completed on 170331 1400. ref SDS M7 UD4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253091 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253092 -              F:\05\00003\SM\CC\CHMG\FNGC\CJGK\achalasia_meds_lesv.xlsx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253094 -         ..
253095 -        Blood pressure added to study, requested by Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253096 -        170419 0900. ref SDS M9 HJ7K  Vitals added to exercise and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253097 -        lipid lab report...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253098 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253099 -              F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253101 -         ..
253102 -    5.  Fundoplication failing, causing continual stricture of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253103 -        requiring frequent dilation.  Doctor planned to research this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253104 -        issue during meeting on 171115 1142. ref SDS O5 XA4F  Discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253105 -        again during meeting on 180124 1130. ref SDS P3 CT56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253107 -         ..
253108 -        Did not discuss today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253109 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253111 -         ..
253112 -    6.  Conscious Sedation with versed - asked Doctor Lee to limit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253113 -        injection of versed to 3 mg, if feasible, and in no case do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253114 -        exceed 5 mg, in order to avoid stroke symptoms on 160617 1637,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253115 -        ref SDS H1 5F6F, following EGD earlier that day when procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253116 -        took 30 minutes, 100% longer, and so versed was increased to 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253117 -        mg, reported on 160617 0800, ref SDS H0 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253119 -  ..
253120 - Also discussed with Crispin, who performed conscious sedation drug                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253121 - injections.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253122 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253123 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253125 -  ..
253126 - Swallowing Has Been Effective Past 4 Weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253127 - 
253128 - Follow up ref SDS P4 VV6N, ref SDS P2 VV6N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253129 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253130 - Reported 1 vomiting event past 8 weeks.  Occurred 6 days ago on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253131 - 180411, shown in case study on 180101 0820. ref SDS O9 RTQR  Only                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253132 - about 10% after dinner.  Follows LESV dilated to 18 mm on 180227 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253133 - ref SDS P4 433O  This has been over 12 months since prior vomitting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253134 - 161125, shown in case study on 160101 0700. ref SDS G1 643I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253136 -  ..
253137 - Bubbles clogging LESV increased the past week.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253139 -  ..
253140 - Burping seems reduced.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253142 -  ..
253143 - No difficulty with digestion using medication protocol, reviewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253144 - during meeting with Doctor Lee on 180124 1130. ref SDS P3 5I5H  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253145 - confirmed prior review the doctor requested on 171206 0830.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253146 - ref SDS O8 QR3L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253147 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253148 -        Famotidine............... 2 40mg pills in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253149 -        Pantoprazole............. 1 40mg pill 30 min before dinner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253150 -        Mylanta.................. 60 ml OA 2200 - 1 hour after statin pills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253151 -        Calcium Carb (Tums)...... 2 500mg pills 30 min after Mylanta                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253152 -        Famotidine............... 2 40mg pills before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253154 -  ..
253155 - Reviewed eating practice - small bites taken with liquid, and mixing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253156 - meat products with other food enables each bite to slip past small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253157 - opening of LESV until next EGD dilates again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253159 -  ..
253160 - Estimated LESV will engage today at 17 mm, since there has been no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253161 - difficulty swallowing, reported on 180108 in case study on 160101                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253162 - 0700. ref SDS G1 UVQV  Maybe less, since past week have started                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253163 - having saliva buildup (bubbles) in esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253165 -  ..
253166 - Requested again consideration for dilating to 19 mm, if the doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253167 - sees minimal ulceration, and there is minimal bleeding on dilating to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253168 - 18 mm.  Doctor Lee will consider this option, which he first presented                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253169 - on 170221 0800. ref SDS M2 EZ6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253170 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253171 -            [...below on 180417 0800 at 1120 Doctor Lee reported he was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253172 -            able to dilate LESV to 19 MM today. ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253173 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253175 -  ..
2532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2534 - 0918                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253501 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253502 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253503 - 
253504 - Follow up ref SDS P4 7V6I, ref SDS P2 7V6I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253506 -  ..
253507 - Everything went smoothly, as always with nurse Frank in the OR today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253509 -  ..
253510 - Frank applied conscious sedation using the catheter Mary set earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253511 - in Preparation, per above. ref SDS P4 544G   Understandings were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253512 - applied on sedation protocol reviewed with Doctor Lee and agreed in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253513 - signing the consent, per above. ref SDS P4 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253515 -  ..
253516 - Did not get name of technical assistant today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253518 -  ..
253519 - The team then did the EDG/dilation procedure with Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253521 -  ..
253522 - Time Start EGD....... 0929                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253523 - Time Out EGD......... 0945                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253525 -  ..
253526 - Total time...........   16 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253528 -   
253529 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253532 -  ..
253533 - LESV Contract 6 MM Dilation 12 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253534 - Meeting Doctor Lee Present Results EGD Dilation Procedure 12 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253535 - Results EGD Dilation Procedure Meeting Doctor Lee Present 12 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253536 - Liquid Diet Continue LESV Contracted 6 MM Worst in Patient History                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253537 - 
253538 - Follow up ref SDS P4 5H5J, ref SDS P2 5H5J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
2536 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2538 - 1100                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2540 -    ..
254001 - Woke up from conscious sedation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254002 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254004 -  ..
2541 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2543 - 1120                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254401 - After the procedure, met with Doctor Lee in the recovery room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254402 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254403 - Before the doctor arrived for discussion, requested copy of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254404 - handwritten report on drugs administered during procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254406 -  ..
254407 - Post Procedure Record shows 800 ML normal saline infused.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254408 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254409 -   
254411 -  ..
254412 - Post Procedure Care Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254413 - Patient received in Recovery 0950 and woke at 1050.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254414 - Blood pressure 117/67 to 149/80  Heart Rate 72 - 52                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254415 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254416 -   
254418 -  ..
254419 - Nursing Procedural Sedation & Analgesia Flow Sheet Record - Page 1 of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254420 - Versed total.............   3 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254421 - Fentanyl total........... 200 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254422 - Benadryl.................  25 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254423 - Lidocaine................   2 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254424 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254425 -   
254426 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254428 -  ..
254429 - Doctor Lee reported good results again today.  He seemed very pleased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254430 - about top of LESV that showed severe ulceration on 160816 0800,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254431 - ref SDS I1 RZ3G, but today there is no further indentation in LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254432 - tissue.  LESV tissue has "grown" back to normal contours.  Everything                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254433 - looks smooth and nomal, shown in photographs taken with gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254434 - during the procedure...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254436 -               ..
254437 -   
254439 -               ..
254440 -   
254442 -               ..
254443 -   
254445 -  ..
254446 - LESV contracted from 18 mm down to 16.5 mm, showing continuing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254447 - improvement compared to severe weekly contractions last year, evident                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254448 - from case study below. ref SDS 0 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254450 -  ..
254451 - Doctor Lee dilated the opening to 19 mm, as discussed during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254452 - meeting this morning, above. ref SDS 0 H14J  Great to finally repeat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254453 - prior dilation to 19 mm, after 6 previous procedures when 19 mm was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254454 - achieved a year ago on 170516 0800. ref SDS N4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254456 -  ..
254457 - This was done in 2 increments, yet still required only 3 mg of versed,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254458 - also discussed this morning, per above. ref SDS 0 639M  Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254459 - started with 15 mm balloon.  It did not begin to dilate LESV until                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254460 - 16.5 mm.  He then inflated the balloon gradually dilating LESV to 18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254461 - mm again, where he observed minor splits in LESV that did not cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254462 - bleeding.  So he inserted the next size ballon and was able to dilate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254463 - LESV to 19 mm, causing more severe splits with bleeding, and so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254464 - stopped dilation procedure.  The record today, continues improvement                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254465 - from prior procedure, when the doctor could only dilate to 18 mm, 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254466 - weeks ago on 180227 0800. ref SDS P4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254468 -  ..
254469 - The doctor indicated the current medication and eating regimens, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254470 - above, ref SDS 0 PD5F, have resolved prior achalasia difficulties,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254471 - i.e., work today demonstrated strong response to treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254472 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254473 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254474 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254475 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Achalasia Spreadsheet Correlate LESV Contractions PPI Triamcinalone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260401 -  ..
260402 - EGD Chart Correlate Time Dilation Triamcinalone Sedation Drugs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260403 - 
260404 - Follow up ref SDS P4 XM3J, ref SDS P2 XM3J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260406 - Excel spreadsheet medications posted from case study exercise, diet,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260407 - vitals, medications...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260408 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260409 -              F:\05\00003\SM\CC\CHMG\FNGC\CJGK\achalasia_meds_lesv.xlsx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260411 -  ..
260412 -                                                                  Bena                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260413 -                                                         Versed/  dryl                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260414 -                    ** MEDICATIONS LESV DILATE  Triamcin Midaz   Diphenhy  Fenta  Lido                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260415 -        Months          PPI FMTDN   from -  to    olone  olam    dramine    nyl   caine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260416 -      Interval  Date     mg   mg     mm     mm      mL     mg      mg       mg     mL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260417 -          2     180417   40  160     16.5   19......1.0.....3......25......250.....10.... ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260418 -          1.50  180227   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260419 -          1.25  180109   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260420 -          1     171128   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS O7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260421 -          2     171031   40  160     15.5   18......1.0.....4......25......250.....10.... ref SDS O3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260422 -          1.53  170905   80   80     15     18......1.0.....3......25......250.....10.... ref SDS N9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260423 -          1.53  170516   80   80     16.5   19......1.0.....5......25......250.....10.... ref SDS N4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260424 -          1.53  170404   80   80     16.5   18......1.5.....5......25......200.....10.... ref SDS M8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260425 -          1.53  170221   80   80     15     18......2.0.....5......25......200......5.... ref SDS M2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260426 -          0.80  170106   80   80     16.5   18......2.0.....5......25......200......5.... ref SDS L6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260427 -          0.23  161213   80   80     15     18......3.0.....5......25......200......5.... ref SDS L0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260428 -          0.20  161206   80   80     11     16.5....1.0.....5......25......200......5.... ref SDS K6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260429 -          0.27  161130   80   80     11     15......0.0.....5......25......200......5.... ref SDS K3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260430 -          0.23  161122   80   80      6     12......0.0.....5......25......200......5.... ref SDS K1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260431 -          1.40  161115   42   80     10     10......0.0.....5......25......200......5.... ref SDS J7 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260432 -          0.83  161004   26   80     11     15......5.0.....5......25......200......5.... ref SDS J1 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260433 -     *1   0.80  160909   80    0     10     15......5.0.....5......25......200......5.... ref SDS I7 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260434 -          2     160816   11   40      9.5   10......5.0.....4......50......150......5.... ref SDS I1 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260435 -          3     160617   10   40      9.5   15......5.0.....6......50......250......5.... ref SDS H0 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260436 -     *2   3     160315   15   40      9.5   15......3.0.....5......25......250......5.... ref SDS G8 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260437 -          8     151204   32   20     10     15......5.0.....5......25......200......5.... ref SDS F4 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260438 -     *3   6     150421   41          16.5   18......3.0.....4......50......250......5.... ref SDS D4 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260439 -          6     141107   37          15     18......4.0.....5......50......150......5.... ref SDS C5 E54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260440 -          6     140509   24          16.5   18..............5......50......200......5.... ref SDS B5 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260441 -     *4   7     131115   24          16.5   18......2.0.....4......50......200......5.... ref SDS A7 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260442 -          3     130416   38          18     18......2.0.....5......50......250......5.... ref SDS A1 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260443 -          4     130110   39          15     18......3.0.....4......50......100......5.... ref SDS 96 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260444 -     *5   6     120925   38          15     18......4.0.....5......50......200......5.... ref SDS 88 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260445 -     *6   4     120322   27          16.5   18..............4......50......150......5.... ref SDS 85 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260446 -     *7   3     111115   76          16.5   18..............4......50......200......5.... ref SDS 82 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260447 -          4     110819   80          15     16.5....2.5.....5......50......200......5.... ref SDS 81 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260448 -          2     110429   80          13     16.5....3.5.....5..............200......5.... ref SDS 76 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260449 -          2     110218   80          11     14......2.0.....4......50......150......5.... ref SDS 72 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260450 -          4     101210   40          11     14......................................5.... ref SDS 67 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260451 -          6     100827    4          11     15..............5......50......250......5.... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260452 -          3     100305    0          11     15..............5......50......250......5.... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260453 -          -     091216               Heller Myotomy Fundoplication................. ref SDS 36 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260455 -         ..
260456 -     ** Dates are from case study on exercise, diet, vitals and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260457 -        medication, shown on 160101, ref SDS G1 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260458 -        previously on 140101. ref SDS B0 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260459 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260460 -     *1 On 160911 paused Pantoprazole to reduce dehydration through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260461 -        frequent urination until after Half Dome, and resumed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260462 -        160920.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260463 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260464 -     *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS B0 E64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260465 -        Resumed Omeprazole 20 mg on 160323. ref SDS G1 RSXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260467 -         ..
260468 -        On 150924 hospitalized hematoma debridement; begin Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260469 -        20 mg per day. ref SDS B0 JT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260470 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260471 -     *3 On 150920 about 5 attacks convulsions, nausea not taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260472 -        Omeprazole - took 40 mg. ref SDS B0 656M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260473 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260474 -     *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260475 -        20 mg for next 5 months. ref SDS A7 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260477 -         ..
260478 -     *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260479 -        20 mg per day, shown in case study on 120101 0900, ref SDS 84                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260480 -        AD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260481 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260482 -     *6 On 120907 Doctor Egan research found Omeprazole increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260483 -        blood pressure, sensed possible correlation patient sudden                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260484 -        rise in blood pressure, recommended reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260485 -        to 20 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260486 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260487 -     *7 On 11115 Doctor Lee prescribed continue PPM 80 mg; on 111201,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260488 -        patient reduced dose to 20 mg on record of rising blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260489 -        pressure despite increased hiking; research indicated PPI may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260490 -        elevate blood pressure, see case study 101010 0744, ref SDS 57 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260491 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260492 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260493 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260494 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260495 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260497 -  ..
260498 - Conscious Sedation Reduced Dose Applied for 16 Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260499 - 
260500 - Follow up ref SDS P4 714N, ref SDS P2 714N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260502 - Nursing Procedural Sedation & Analgesia Flow Sheet Record Page 1 shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260503 - versed 3 ML.  Since procedure only took 16 minutes, the doctor was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260504 - able to minimize exposure to versed, which previously caused stroke                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260505 - symptoms with 6 ml, as occurred on 160617 0800. ref SDS H0 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260507 -  ..
260508 - No post procedure side effects as occurred on 161213 0800. ref SDS L0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260509 - R74J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260511 -  ..
260512 - Seem very sleepy though even hours after the procedure using just 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260513 - ml versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260514 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260516 -  ..
260517 - Ulceration Improved Stricture Decreased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260518 - 
260519 - Follow up ref SDS P4 RZ3G, ref SDS P2 RZ3G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260521 - Doctor Lee presented pictures showing improved condition with reduced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260522 - ulceration of LESV, following EGD dilation procedure today, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260523 - ref SDS 0 GD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260525 -  ..
260526 - He advised that severe ulceration has continued to be completely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260527 - resolved.  The prior ulceration hole adjacent to LESV opening in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260528 - esophagus found during the procedure on 161115 0800, ref SDS J7 K44N,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260529 - and continuing remnants of ulceration found during EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260530 - 161122 1245, ref SDS K0 RZ3G, is still no longer visible.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260532 -  ..
260533 - As a result, the doctor was able to dilate LESV from 16.5 - 19mm,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260534 - shown in the table above. ref SDS 0 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260536 -  ..
260537 - Today, Doctor Lee wants to continue Pantoprazole 40 mg and Famotidine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260538 - 160 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260539 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260540 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260542 -  ..
260543 - Schedule Next Procedure and Post Procedure Review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260544 - 
260545 - Follow up ref SDS P4 XF6X, ref SDS P2 XF6X.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260547 - Asked about his daughter attending college?  The doctor said his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260548 - daughter received acceptance offers from 3 schools in the UC system,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260549 - and 1 from a college in Chichago.  Finally coached him to say the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260550 - college in Chicago is Loyola University.  His daughter wants to attend                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260551 - there.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260553 -  ..
260554 - Doctor Lee wants next EGD Dilation procedure in 4 - 6 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260556 -  ..
260557 - He said this will have to be an overbook.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260559 -  ..
260560 - Doctor Lee further ordered consult in 3 weeks, which will also have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260561 - to be an overbook.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260563 -  ..
260564 - Doctor Lee said another patient is waiting for treatmet, so he does                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260565 - not have time to check his schedule to determine overbook dates.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260566 - asked Paul to work on this tomorrow, when he calls to check on patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260567 - response to treatment performed today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260569 -  ..
260570 - Thanked Doctor Lee for good work today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260572 -  ..
260573 - Paul submitted a pink sheet with Doctor Lee's prescription for next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260574 - procedure and consult.  He said to give the pink sheet to the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260575 - receptionist at the front desk.  She will schedule dates available in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260576 - the computer.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260578 -  ..
260579 - Tomorrow Paul will call to check on patient response to treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260580 - During that call Paul will work on implementing the doctor's order for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260581 - follow up EGD in 6 - 8 weeks and consult in 3 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260582 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260583 -            [On 180418 0932 Paul called from GI Clinic at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260584 -            Center in Sacraento; he will consult with Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260585 -            scheduling consult in 3 weeks, and next EGD dilation in 6 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260586 -            8 weeks. ref SDS P6 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260588 -             ..
260589 -            [On 180423 1017 letter to Jessica requesting she notify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260590 -            Doctor Lee to call about scheduling meeting and next EGD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260591 -            ref SDS P7 OA3W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260593 -             ..
260594 -            [On 180425 1130 Kathy met with Jessica and at that time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260595 -            Jessica scheduled next EGD on 180605 0800, she scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260596 -            review meeting 6 weeks later on 180711, the next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260597 -            dilation was scheduled 2 days later on 180713, and review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260598 -            meeting was scheduled 6 days later on 180719.   The review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260599 -            meeting ordered by Doctor Lee for 3 weeks after recent EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260600 -            on 180417, is still not scheduled. ref SDS P8 9O6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260601 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260602 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260609 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2703 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270401 -  ..
270402 - Progress Notes EGD Procedure on 180417 Received on 180625                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270403 - 
270404 - Follow up ref SDS P4 Q05K, ref SDS P2 Q05K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270406 -  ..
270407 - On 180625, received this file downloaded from VA Internet server.  It                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270408 - was signed by the doctor on 180527, and includes numerous reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270409 - flowing from EGD Dilation procedure on 180417.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270410 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270411 -              https://www.myhealth.va.gov/mhv-portal-web                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270412 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270419 -  ..
270420 - Progress Notes stored in...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270421 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270422 -              F:\05\00003\SM\CC\AGMJ\20180417-080000\mhv_WELCH_20180625_1120.txt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270423 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270425 -  ..
270426 - Progress Notes EGD Dilation Today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270427 - 
270428 - Follow up ref SDS P4 9N5G, ref SDS P2 9N5G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270429 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270430 -    1.  Date/Time:               17 Apr 2018 @ 0800                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270431 -        Note Title:              EGD 60111                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270432 -        Location:                No CA Healthcare Sys-Martinez                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270433 -        Signed By:               LEE,RANDALL E                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270434 -        Co-signed By:            LEE,RANDALL E                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270435 -        Date/Time Signed:        17 Apr 2018 @ 1018                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270436 -        -------------------------------------------------------------------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270438 -         ..
270439 -        LOCAL TITLE: EGD 60111                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270440 -        STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270441 -        DATE OF NOTE: APR 17, 2018@08:00     ENTRY DATE: APR 17, 2018@10:17:53                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270442 -        AUTHOR: LEE,RANDALL E        EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270443 -        URGENCY:                            STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270444 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270445 -           *** EGD 60111 Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270447 -         ..
270448 -        EGD 1953322:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270449 -        GE junction stricture at 39cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270450 -        no active ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270451 -        TTS balloon dilated 16.5 to 19mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270452 -        triamcinolone acetate 40mg/ml injected 0.5ml x3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270453 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270454 -        /es/ Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270455 -        Staff Physician, Gastroenterology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270456 -        Signed: 04/17/2018 10:18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270457 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270458 -        04/17/2018 ADDENDUM                      STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270460 -         ..
270461 -    2.  PATIENT NAME:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270465 -         ..
270466 -        DATE OF BIRTH: 03/01/1945                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270468 -         ..
270469 -    3.  NAME OF PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270470 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270471 -        1.  Esophagogastroduodenoscopy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270472 -        2.  TTS balloon dilation of esophageal stricture.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270473 -        3.  Endoscopic triamcinolone injection.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270475 -         ..
270476 -        ATTENDING PHYSICIAN:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270477 -        Randall E. Lee, M.D.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270479 -         ..
270480 -    4.  INDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270481 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270482 -        Rodney Charles Welch is a 73-year-old man with underlying history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270483 -        achalasia.  He had laparoscopic myotomy and fundoplication at San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270484 -        Francisco VA in 2009.  This relieved his achalasia associated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270485 -        dysphagia, but he subsequently developed esophageal reflux strictures                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270486 -        and has required repeated endoscopic dilations.  His most recent EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270487 -        and dilation was February 2018 at which time his stricture was dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270488 -        from 16.5-18 mm.  Triamcinolone acetate was injected at a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270489 -        concentration of 20 mg/mL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270491 -         ..
270492 -        In the interim over the past week has noted some recurrence of saliva                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270493 -        building up in the esophagus and only 1 episode of food impaction                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270494 -        requiring vomiting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270496 -         ..
270497 -    5.  CONSENT:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270498 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270499 -        The risks, benefits, and alternatives to this procedure including but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270500 -        not limited to the risks of bleeding and bowel perforation were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270501 -        explained to the patient.  The patient understood and provided written                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270502 -        informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270504 -         ..
270505 -    6.  INTRAVENOUS MEDICATION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270507 -        1.  Diphenhydramine 25 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270508 -        2.  Fentanyl 200 mcg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270509 -        3.  Midazolam 3 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270511 -         ..
270512 -    7.  PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270513 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270514 -        In the Sacramento VA GI Endoscopy Unit, the patient was placed in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270515 -        left lateral decubitus position.  Oxygen at 2 liters per minute by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270516 -        nasal cannula was administered.  Continuous oximetric and hemodynamic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270517 -        monitoring was initiated.  Intravenous sedation was administered in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270518 -        divided doses.  A bite block was placed in the patient's mouth and an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270519 -        Olympus GIF-HQ190 videogastroscope was advanced under direct vision to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270520 -        the esophagus.  The GE junction was noted at 39 cm and was easily                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270521 -        traversed by the gastroscope without resistance or trauma.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270522 -        gastroscope was advanced into the third portion of the duodenum.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270523 -        Retroflexed views of the incisura, fundus, and cardia were performed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270524 -        A TTS balloon was positioned across the lower esophageal sphincter and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270525 -        the balloon was inflated sequentially from 15-16.5-18 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270526 -        Circumferential contact was noted at 15 mm.  No visible trauma was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270527 -        noted until expansion to 16.5 mm.  The balloon was deflated, removed,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270528 -        and replaced with a second larger balloon.  This was inflated from 18-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270529 -        19 mm.  The balloon was deflated, removed, and 3 areas of mucosal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270530 -        damage were injected with submucosal injections of triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270531 -        acetate at a concentration of 40 mg/mL.  Injections were made at 0.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270532 -        mL aliquots.  Total volume was 1.5 mL.  The stomach was decompressed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270533 -        and the gastroscope removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270535 -         ..
270536 -    8.  COMPLICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270538 -        None immediate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270540 -         ..
270541 -    9.  FINDINGS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270543 -        1.  Dilated proximal, mid, and distal esophageal body without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270544 -            peristaltic waves.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270546 -        2.  Smooth esophageal mucosa without significant defects.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270548 -             ..
270549 -        3.  Previously identified mucosal defect at site of prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270550 -            esophageal ulcers at about 35 cm from the incisors.  These                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270551 -            continued to remain fully epithelialized without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270552 -            surrounding erythema, edema or active ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270554 -             ..
270555 -        4.  GE junction stricture at 30 cm without ulceration, erythema                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270556 -            or mass effect.  Initial diameter continues to be 16.5 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270557 -            as sized by the balloon.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270559 -             ..
270560 -        5.  Gastric fundus appearance consistent with prior history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270561 -            fundoplication with recurrent small hiatal hernia and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270562 -            occasional prolapse of gastric mucosa into the hiatal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270563 -            hernia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270565 -             ..
270566 -        6.  Normal gastric mucosa in the fundus and body.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270568 -             ..
270569 -        7.  Patchy gastric antral erythema without erosion, ulceration or mass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270570 -            effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270572 -             ..
270573 -        8.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270575 -             ..
270576 -        9.  Normal duodenum to D3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270578 -         ..
270579 -   10.  IMPRESSION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270580 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270581 -        Distal esophageal stricture dilated from approximately 16.5 to 19 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270582 -        No evidence of acute inflammation.  No evidence of malignancy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270584 -         ..
270585 -   11.  RECOMMENDATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270586 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270587 -        1.  Continue with current medical therapy with famotidine and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270588 -            pantoprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270589 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270590 -        2.  Repeat EGD and dilation in approximately 8 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270592 -             ..
270593 -        3.  Continue periodic washout of esophageal body with carbonated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270594 -            beverages to avoid candida esophagitis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270595 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270597 -         ..
270598 -   12.  DISPOSITION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270599 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270600 -        1.  The patient was observed in the Recovery Room then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270601 -            discharged to home with a companion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270602 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270603 -        2.  I reviewed the endoscopic findings and recommendations with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270604 -            the patient prior to discharge.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270607 -         ..
270608 -        TIME START: 0929 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270609 -        TIME END:   0945 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270611 -         ..
270612 -        Total time:   16 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270614 -         ..
270615 -        D:  04/17/2018                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270616 -        T:  04/18/2018                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270617 -        Job number:  1953322                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270618 -        LRM/CMTS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270619 -        $end:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270620 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270621 -        /es/ Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270622 -        Staff Physician, Gastroenterology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270623 -        Signed: 05/27/2018 22:03                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270624 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270625 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270626 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270627 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270628 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270629 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2707 -