CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2503 -    ..
2504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
2505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250501 - Follow up ref SDS S8 0000. ref SDS S4 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250503 - *******************************************************                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250504 - ********** Content Prior Record Begins Here ***********                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250505 - *******************************************************                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250507 -  ..
250508 - No diffuculty swallowing this cycle with LESV dilated to 20 mm 4 weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250509 - ago on 190118. ref SDS S4 VV6N  No difficulty with digestion using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250510 - medication and eating protocols reviewed during meeting with Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250511 - Lee on 181127. ref SDS S4 PD5F  Signed blank consent for the procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250512 - today, on assurance that stroke symptoms following prior EGD on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250513 - 160617, with mild recurrence on 161213, would not occur.  Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250514 - was pressed for time today, so deferred agenda issues to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250515 - post-procedure meeting in 3 weeks. ref SDS S4 KT9M  EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250516 - procedure went smoothly, with no reports of difficulties. ref SDS S4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250517 - 7V6I  Gastroscope in and out took 10 minutes, ref SDS S4 UT4N, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250518 - versed sedation medication required only 3 ML, well below 6 ML that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250519 - caused prior symptoms. ref SDS S4 CR4F  Post procedure Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250520 - reported good results with LESV contracting to only 19 mm, so he was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250521 - able to dilate LESV back to 20 mm.  Ulceration remained improved over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250522 - the past 8 weeks, which enabled the doctor to dilate LESV needed for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250523 - better swallowing. ref SDS S4 RZ3G  Continued improvement in ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250524 - and LESV dilation shows good response to treatment with prescribed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250525 - medications. ref SDS S4 JK6N  Scheduled next EGD dilation in 4 weeks,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250526 - and consult in 2 weeks to review pending issues. ref SDS S4 XF6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250529 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250532 -  ..
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 66 BE7K - dilated LESV again from 11 to 14                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251079 - mm. ref SDS 66 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251081 -  ..
251082 - On 101216 1021 letter commends medical team for excellent work, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251083 - confirms schedule next EGD on 110218 0730. ref SDS 68 K35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251085 -  ..
251086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251087 - anesthesia with Fentanyl. ref SDS 71 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 71 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 75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 75 U23I, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251097 - triamcinolone injections were continued. ref SDS 75 SS5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251099 -  ..
251100 - On 110607 1414 visited GI Department, ref SDS 77 HC5H, and Charlene                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251101 - reported a computer mistakes requires scheduling next EGD dilation on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251102 - 110819 0830. ref SDS 77 N642  Requested meeting with Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251103 - review pending action items. ref SDS 77 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 80 J978, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251110 - triamcinolone injections were continued. ref SDS 80 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 81 IR57; for some reason triamcinolone injections to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251116 - resist contraction of LESV was not performed. ref SDS 81 IS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251118 -  ..
251119 - On 111201 0928 seems to be 10% increase in blood pressure the past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251120 - month, ref SDS 82 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 84 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 84 UI9H  LESV dilated from 16.5 - 18 mm. ref SDS 84                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251133 - 516N  Triamcinolone injections to resist contraction of LESV was not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251134 - performed. ref SDS 84 5179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251136 -  ..
251137 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251138 - business unit; reported patient history. ref SDS 87 RG9K  Scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251139 - EGD and dilation procedure for 1300; returned and performed procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251140 - ref SDS 87 TB4J; dilated from 15 mm to 18 mm. ref SDS 87 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251141 - Swallowing and vomitting problems increased after omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251142 - triamcinolone steriod injections to resist contraction of LESV after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251143 - dilation, ref SDS 87 TZ4M; therefore, injections were resumed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251144 - complement dilation to enable and maintain effective swallowing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251145 - ref SDS 87 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 95 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251152 -  ..
251153 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251154 - remained at 18 MM, ref SDS A0 CO5N, same as dialated 4 months earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251155 - on 130110 0900. ref SDS 95 Q333  Report CT test on 130117, shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251156 - esophagus fully recovered from severe distortions caused by achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251157 - 8 years earlier. ref SDS A0 MT6F  Doctor Lee injected steriod again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251158 - maintain swallowing. ref SDS A0 F38G  Prescribed reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251159 - to 1 pill per day. ref SDS A0 R74M  Scheduled next EDG dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251160 - months, instead of 3. ref SDS A0 6P6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251162 -  ..
251163 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251164 - to 18 mm. ref SDS A6 CO5N  Triamcinolone steriod injected again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251165 - maintain improved swallowing. ref SDS A6 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 A6 R74M  Biopsies taken. ref SDS A6 3N8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251169 -  ..
251170 - On 131121 1604 ordered refill of Omeprazole to aid digestion.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251171 - is 1 refill remaining. ref SDS A7 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251173 -  ..
251174 - On 131205 1443 received order for Omeprazole prescription placed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251175 - 131121. ref SDS A8 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251177 -  ..
251178 - On 140318 1043 received letter cancelling meeting scheduled for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251179 - EGD/Dilation procedure on 140425 1000, ref SDS B1 935L; a second                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251180 - letter scheduled prodedure on 140509 0900. ref SDS B1 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 B2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251185 - 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251187 -  ..
251188 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251189 - center in Sacramento, Mather. ref SDS B4 K37G  Pre-op preperation went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251190 - well - IV setup on first stick. ref SDS B4 EP75  Doctor ordered refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251191 - for Omeprazole. ref SDS B4 AW5O  Doctor patient partnership continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251192 - to progress with doctor reading up on patient history to be prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251193 - for effective meeting. ref SDS B4 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 B4 0N6I  Reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251196 - swallowing and vomitting problems reduced past 6 months with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251197 - triamcinolone steriod injections to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251198 - ref SDS B4 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 B4 5H5J, scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251201 - next EGD dilation in 6 months since this worked well the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251202 - with triamcinolone steriod injections. ref SDS B4 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 B4 I167  Progress notes report small tearing of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251206 - LESV during dilation procedure. ref SDS B4 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251208 -  ..
251209 - On 140718 1017 planning for notifying VA to update current fill date                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251210 - for Omeprazole. ref SDS B8 U88L  Kathy visited VA in Sacramento, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251211 - requested changing refill date for Omeprazole to 140718. ref SDS B8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
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 B8 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 C0 W83K, based on history rising vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251220 - swallowing problems, shown in patient history case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251221 - beginning 140712. ref SDS 83 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 C1 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 C2 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 C3 K37G  Submit record showing normal swallowing occurs longer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251239 - with triamcinolone steriod injection to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251240 - ref SDS C3 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 C3 3U66  Notified results of Half Dome hike.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251243 - ref SDS C3 3U6Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251245 -  ..
251246 - On 141107 0800 EGD dilation procedure - setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251247 - sedation required 3 sticks. ref SDS C4 5W5I  Meeting Doctor Lee guided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251248 - by agenda facilitated collaboration through doctor patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251249 - partnership. ref SDS C4 VV6N  Doctor explained increased difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251250 - swallowing due to experiment omitting triamcinalone steriod injection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251251 - on prior procedure, ref SDS C4 4U8I, shown by LESV contracting back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251252 - from 15 mm. ref SDS C4 T55I  Progress Notes report finding ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251253 - and hiatal hernia. ref SDS C4 MG6N  Photographs seem to show                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251254 - significantly different condition of fundoplication from a year                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251255 - earlier. ref SDS C4 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 D0 0M6I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251261 - Lee advised that increased orange juice consumption aids digestion,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251262 - and presents no health risks. ref SDS D0 YF5M  Scheduled next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251263 - dilation procedure on 150421 1300. ref SDS D0 PS4O  Fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251264 - failure increases acid burn that caused ulceration with hiatal hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251265 - with increased recurrance achalasia. ref SDS D0 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 D0 JQ5J  Doctor Lee completed Progress Notes for EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251269 - on 141107. ref SDS D0 PS53  Doctor Lee will recommend Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251270 - order CT test to evaluate recurrance achalasia due to failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251271 - fundoplication. ref SDS D0 TH5M  This test can include coronary CTA to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251272 - evaluate regression atherosclerosis. ref SDS D0 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 D2 0M6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251278 -  ..
251279 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251280 - (Mather). ref SDS D3 K37G  No difficulties setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251281 - sedation. ref SDS D3 5W5I  Reported pain level 2 right knee MCL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251282 - ref SDS D3 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 D3 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 D3 P55L, and shown by EGD dilation LESV from 16.5 mm back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251288 - 18 mm. ref SDS D3 HU42  Progress Notes report findings of hiatal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251289 - hernia. ref SDS D3 QD6O  Impression today that ulceration has subsided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251290 - to mere errosions seems promising. ref SDS D3 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 D5 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 D7 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 D8 3E4I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251309 - Stewart explained redo Dor Fundoplication required for "repairing"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251310 - original surgery, presents high risk of collateral damage. ref SDS D8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
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 D8 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 E1 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 E2 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 E3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
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 E3 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 E5 5G8T  As a result, Pharmacy VA Medical Center San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251350 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS E5 FK66                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251352 -  ..
251353 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251354 - 0800. ref SDS E5 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 E6 NV5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251362 -  ..
251363 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251364 - prescription. ref SDS D4 0C5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251366 -  ..
251367 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251368 - (Mather); initial administration went well. ref SDS F3 GD4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251369 - Preparation for the procedure was professional; no difficulties                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251370 - setting IV for conscious sedation today. ref SDS F3 544G  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251371 - reported not receiving letter with agenda for the meeting today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251372 - submitted on 151201. ref SDS F3 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 F3 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 F3 G53K  Performing EGD dilation procedure went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251380 - smoothly, with no difficulties. ref SDS F3 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 F3 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 F6 J56O  Doctor prescribed adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251392 - Famotidine an H2 blocker taken once a day to compliment Omeprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251393 - ref SDS F6 YL3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251395 -  ..
251396 - On 160325 0900 Diffuculty swallowing this cycle began about 1 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251397 - after prior EGD dilation on 151204. ref SDS G7 P55L  Reported using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251398 - baking soda to relieve reflux that prevents ulceration LESV; this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251399 - reduced Omeprazole in order to avoid dehydration. ref SDS G7 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 G7 PXXY  EGD dilation procedure went smoothly, with no reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251404 - of difficulties. ref SDS G7 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 G7 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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251419 -  ..
251420 - On 180417 0800 at 1120 Doctor Lee reported he was able to dilate LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251421 - to 19 MM, the most ever. ref SDS P6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251423 -  ..
251424 - On 180425 1130 Kathy met with Jessica and at that time Jessica                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251425 - scheduled next EGD on 180605 0800, she scheduled review meeting 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251426 - weeks later on 180711, the next EGD dilation was scheduled 2 days                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251427 - later on 180713, and review meeting was scheduled 6 days later on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251428 - 180719.   The review meeting ordered by Doctor Lee for 3 weeks after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251429 - recent EGD on 180417, is still not scheduled. ref SDS P9 9O6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251431 -  ..
251432 - On 180924 0900 meeting with Doctor Summana Jothi at VA Clinic in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251433 - Martinez, determined larynx has slight opening, not enough to cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251434 - occasinoal pronounced scratchy voice.  Reported caused by saliva                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251435 - becoming backed up, because cannot go through LESV ref SDS R3 OL5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251436 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251437 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251438 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251439 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251440 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251442 -  ..
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 S8 NU8L, ref SDS S4 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251806 - EGD treatment with Doctor Lee today, aligns with the doctor deciding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251807 - to perform these procedures every 4 weeks for the next year, reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251808 - on 180711 0900. ref SDS Q8 RE9L  Jessica later issued new schedule for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251809 - a year ahead, and showing EGD dilation today, about 4 weeks after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251810 - prior procedure on 190319 0800. ref SDS S8 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251812 -  ..
251813 - In another record today, Jessica cancelled EGD procedures scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251814 - through December, and then scheduled these procedures using a new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251815 - system, reported on 190416 0800. ref SDS S9 5K7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251817 -  ..
251818 - Applied pre-proc requirements for NPO after midnight, from letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251819 - 101015 1547. ref SDS 58 4J9L  Last food was at......                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251821 -  ..
251822 - Drove to Sacramento from Concord on Wednesday, and stayed at Kathy's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251823 - house about 3 miles from VAMC Sacramento.  Yesterday, worked on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251824 - entering record of PRP treatments and follow correspondence the past 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251825 - weeks.  This morning drove to the VA for EGD treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251826 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251828 -  ..
2519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2521 - 0728                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252201 - Arrived at VAMC Sacramento.  Checked into GI Department at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252202 - customer counter..                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252204 -  ..
252205 - Said hello to Jennifer, who was in the hallway with another janitor.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252207 -  ..
252208 - Sonja was in her office adjacent to the checkin counter.  She came out                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252209 - and said the meeting with Doctor Lee scheduled for 0800, has been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252210 - moved to 1300, because the doctor had a conflict this morning at 0800                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252211 - for personal business.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252213 -  ..
252214 - Sonja called Jessica, and they talked for a minute.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252216 -  ..
252217 - Went upstairs and met with Jessica, and agreed to return at 1300, for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252218 - Doctor Lee to perform EGD dilation, reported in another record today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252219 - on 190416 0800. ref SDS S9 TZ5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252221 -  ..
252222 - Kathy drove me home to wait until 1300.  She left to do errands.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252223 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252225 -  ..
2523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2525 - 0926                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252601 - Received call from Grace.  she said Doctor Lee is already onsite, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252602 - would like to do the EGD as soon as possible.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252604 -  ..
252605 - Called Kathy.  She is 10 minutes from the house.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252607 -  ..
252608 - After she returned, we drove back to the VA, about 3 miles from her                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252609 - house.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252610 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252612 -  ..
2527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2529 - 0952                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253001 - Arrived back at the VAMC GI Clinic.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253003 -  ..
253004 - Rosie did vitals.  Great to see her back at work this morning,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253005 - following recovery from surgery for lung cancer about 8 months ago.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253006 - She said everybody at work has been very helpful and supportive.  She                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253007 - wanted to come back because they are all her friends.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253009 -  ..
253010 - Send Rosie flowers.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253012 -  ..
253013 - Vitals were taken today, and found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253014 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253015 -            Weight.................. 188                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253016 -            BP...................... 136 65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253017 -            HR (pulse).............. 59                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253018 -            Oxygen.................. 98                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253019 -            Temp.................... 97.0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253021 -  ..
253022 - Rosie asked more medical questions than typically asked in the past,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253023 - indicating possible change in procedures.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253024 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253026 -  ..
253027 - Kathy cell phone for designated driver...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253031 -  ..
253032 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253033 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253034 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253035 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253036 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253037 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253038 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253040 -  ..
2531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2533 - 1000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253401 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253402 - 
253403 - Follow up ref SDS S8 EP75, ref SDS S4 EP75.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253405 - No objections nor concerns today, as occurred previously on 161115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253406 - 0800, ref SDS J7 WA5I, and again on 161130 1038. ref SDS K3 EP75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253408 -  ..
253409 - Saw Clair upstairs, while meeting with Jessica, reported in another                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253410 - record today on 190416 0800. ref SDS S9 BJ8I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253412 -  ..
253413 - Danis did initial patient setup.  Most information entered today for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253414 - patient identification and medical history was the same.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253416 -  ..
253417 - She asked about pain?  Reported level 0.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253419 -  ..
253420 - Gracie set catheter IV for sedation.  She was successful on 1st stick                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253421 - in right inner arm about 4" below elbow; 1st stick was pain level 3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253422 - Veins develop adhesions (scar tissue) that take time to heal, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253423 - prevent blood flow into the IV needle.  This morning ran hot water in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253424 - the shower to cause veins to dilate.  Also, onsite at the hospital,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253425 - did 10 pushups to further dilate veins in the forearm, where the IV is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253426 - set, because patient is rolled onto left side for the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253428 -  ..
253429 - Case study on sticks required to set catheter is reported on 110429                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253430 - 1230. ref SDS 76 UO3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253432 -  ..
253433 - Gracie and Danis both said voice seems normal today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253435 -  ..
253436 - They worked quickly today, because Doctor Lee was already onsite and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253437 - anxious to perform the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253439 -  ..
253440 - Ann is the nurse in the room today.  She set blood pressure cuff and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253441 - EKG probes, that will be used during the procedure to monitor vitals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253443 -  ..
253444 - Complimented the team saying they worked together very well today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253445 - like a pitstop crew at the Indianopolis 500.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253446 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253447 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253448 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253450 -  ..
2535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2536 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2537 - 1015                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2538 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253801 - Meeting Doctor Lee and Consent for Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253802 - 
253803 - Follow up ref SDS S8 GG6G, ref SDS S4 GG6G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253804 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253805 - Doctor Lee asked questions on patient history to verify ready for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253806 - procedure, e.g., no allergies, and NPO after midnight to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253807 - conflicts with anesthesia; no health problems, e.g., no diabetes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253808 - alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253810 -  ..
253811 - Doctor Lee asked about medication regimen?  Reported the regimen he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253812 - prescribed originally on 181127 0800, ref SDS R7 OI8F, and decided to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253813 - return to it after the last EGD a month ago on 190118 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253814 - ref SDS S1 U44O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253816 -  ..
253817 - This morning he confirmed the following prescription...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253818 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253819 -        Famotidine............... 2 40mg pills in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253820 -        Pantoprazole............. 1 40mg pill 30 min before dinner every other day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253821 -        Famotidine............... 2 40mg pills before dinner every other day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253822 -        Mylanta.................. 40 ml OA 2200 - 1 hour after statins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253823 -        Calcium Carb (Tums)...... 2 500mg pills 30 min after Mylanta                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253824 -        Famotidine............... 2 40mg pills before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253826 -  ..
253827 - Eating regimen is shown in case study of daily diet, medication,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253828 - exercise and vitals, reported on 190101 0730. ref SDS S0 QJ5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253829 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253830 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253831 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253832 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253834 -  ..
2539 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2540 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2541 - 1008                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254201 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254202 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254203 - 
254204 - Follow up ref SDS S8 KT9M, ref SDS S4 KT9M.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254205 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254206 - Doctor Lee presented a digital tablet and requested signature to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254207 - consent for the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254209 -  ..
254210 - Noted that signature is entered on completely black screen, required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254211 - without reading online documents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254213 -  ..
254214 - Advised that signature is based on following understandings...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254215 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254216 -    1.  Ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254217 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254218 -        Where is this shown in photographs taken on 190319?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254219 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254220 -              F:\05\00003\SM\CC\AGMJ\20190319-080000\MAC00029945550.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254222 -         ..
254223 -        Stopped pain medication on 190317, shown in case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254224 -        190101 0730. ref SDS S0 PWYS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254226 -         ..
254227 -        We should see reduced or resolved ulceration today...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254229 -  ..
254230 - Doctor Lee pointed to "white" area that appears protruding on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254231 - right side of image 5, as showing evidence of ulceration found during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254232 - prior EGD on 190319 0800. ref SDS S8 RZ3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254233 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254234 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254236 -         ..
254237 -    2.  Ensure order refill.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254239 -  ..
254240 - Doctor Lee said he will enter another order for Ensure.  This is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254241 - reported today, in another record on 190416 1017. ref SDS T0 4G4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254243 -  ..
254244 - Next day, there is no ordere for Ensure shown in VA online drug                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254245 - ordering system.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254246 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254247 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254249 -         ..
254250 -    3.  Voice less very scratchy following examination and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254251 -        recommendations by Doctor Lee during prior EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254252 -        181218 0800. ref SDS R8 RX8I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254254 -         ..
254255 -        Voice better concentrating on washing throat with carbonated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254256 -        beverage after each bite of food during meals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254258 -         ..
254259 -        Voice also better after recent increase dilating LESV to 20 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254260 -        has improved swallowing, compared to prior practice dilating to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254261 -        only 18 mm.  This has also improved voice function.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254263 -  ..
254264 - Doctor Lee concurred voice better this morning after NPO since                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254265 - yesterday 1800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254266 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254268 -         ..
254269 -    4.  Pantoprazole Reduced Regimen Reduced Frequent Urination.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254270 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254271 -        Effective taking 1 40 mg pill every other day,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254272 -        and with Famotidine 2 40 mg pills in morning every day, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254273 -        before dinner every other day, and before going to bed every                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254274 -        day, prescribed by Doctor Lee after the previous EGD on 190118                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254275 -        0800. ref SDS S1 U44O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254277 -  ..
254278 - Doctor Lee reviewed the study displayed on c23, correlating frequent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254279 - urination with taking Pantoprazole every other day at dinner time, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254280 - taking Famotidine every other day at dinner, per regimen above,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254281 - ref SDS S8 KG8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254283 -  ..
254284 - Study shows significant decline in frequent urination, from 181218,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254285 - when the doctor prescribed Pantoprazole every day, compared to the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254286 - period following 190118, when Pantoprazole was reduced to every other                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254287 - day, shown in the record on 190101 0730. ref SDS S0 T14L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254289 -  ..
254290 - As a result, the doctor said to continue taking Pantaprozole every                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254291 - other day before dinner, and take Famotidine on the days when not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254292 - taking Pantaprozole before dinner.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254293 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254295 -         ..
254296 -    5.  Hiatal Hernia - can this subside or otherwise improve over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254297 -        time with any action by patient, similar to ulceration of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254298 -        recovering by ending naproxen, and adding carbonated beverage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254299 -        to washout esophagus during meals?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254301 -         ..
254302 -        What drives worsening of hiatal hernia?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254304 -  ..
254305 - Did not discuss this today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254306 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254308 -         ..
254309 -    6.  Esophagus PRP restores muscle strength to push saliva and food                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254310 -        through narrow LESV.  Doctor Jothi is doing these procedures                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254311 -        for patients who have no alternatives, reported on 180924 0900.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254312 -        ref SDS R3 IU62                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254314 -  ..
254315 - Advised getting PRP treatment at VAMCSF for knees and elbow,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254316 - scheduled on 190425, being performed by Doctor Edwards.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254318 -  ..
254319 - Doctor Lee seemed very pleased, the VA is now supporting this line of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254320 - care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254321 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254323 -         ..
254324 -    7.  Dilation 18 - 20 mm, shown in Recommendation #3 for Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254325 -        Notes on EGD performed 180814.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254327 -         ..
254328 -        Assess today, toward maintaining reduced medication dose, or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254329 -        increase dose on findings of ulceration LESV recurrance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254331 -  ..
254332 - Today, Doctor Lee dilated LESV from 18 to 20 mm, shown in Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254333 - Notes received on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254334 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254335 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254337 -         ..
254338 -    8.  Fundoplication failing, causing continual stricture of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254339 -        requiring frequent dilation.  Doctor planned to research this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254340 -        issue during meeting on 171115 1142. ref SDS O5 XA4F  Discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254341 -        again during meeting on 180124 1130. ref SDS P3 CT56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254343 -         ..
254344 -        On 180627 1300 Doctor Patel seemed to say GI Clinic at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254345 -        has investigated viability of gastroscope fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254346 -        procedures.  He seemed to further advise that the clinic has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254347 -        referred patients for gastroscope full fundoplication, but not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254348 -        to repair fundoplication. ref SDS Q6 JX9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254350 -         ..
254351 -        We reviewed the record in this case that Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254352 -        performed Dor fundoplication on on 091216, as shown Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254353 -        Notes received on 100928 0706. ref SDS 56 VK8F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254355 -         ..
254356 -        At tht time on 180627 1300 asked Doctor Patel to review with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254357 -        the GI team prospects to repair Dor Fundoplication in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254358 -        reduced reflux that continually causes stricture that closes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254359 -        down LESV, requiring repeated EGD dilations on close intervals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254360 -        ref SDS Q6 HP4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254362 -  ..
254363 - Did not discuss today, because seem to be managing reflux well enough                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254364 - to minimize formation of stricutre, so that swallowing is not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254365 - impaired, thus avoiding vomiting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254366 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254368 -         ..
254369 -    9.  Conscious Sedation with versed - asked Doctor Lee to limit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254370 -        injection of versed to 3 mg, if feasible, and in no case do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254371 -        exceed 5 mg, in order to avoid stroke symptoms on 160617 1637,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254372 -        ref SDS H0 5F6F, following EGD earlier that day when procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254373 -        took 30 minutes, 100% longer, and so versed was increased to 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254374 -        mg, reported on 160617 0800, ref SDS G9 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254376 -  ..
254377 - This was discussed with Doctor Lee, and Anna was present.  She will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254378 - be administering drugs, and so this briefing was helpful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254379 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254380 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254381 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254382 -   10.  Barium Swallow Test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254384 -  ..
254385 - Did not discuss today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254386 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254387 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254388 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254389 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254391 -  ..
254392 - Swallowing Has Been Effective Past 4 Weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254393 - 
254394 - Follow up ref SDS S8 VV6N, ref SDS S4 VV6N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254395 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254396 - Reported 0 vomiting event past 4 weeks since prior EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254397 - 190118 0800. ref SDS S1 VV6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254399 -  ..
254400 - Doctor Lee glanced through case study on 190101 showing exercise,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254401 - diet, medication and vitals.  He feels record on typical diet and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254402 - eating for 190109, aligns with requirments for effective swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254403 - under achalasia. ref SDS S0 QVPV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254405 -  ..
254406 - Bubbles clogging LESV seems reduced this cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254408 -  ..
254409 - Burping seems reduced.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254411 -  ..
254412 - Dilating LESV to 20 mm first achieved on 181002, has been a good                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254413 - factor.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254415 -  ..
254416 - No difficulty with digestion using eating and medication protocols,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254417 - reviewed today, per above, ref SDS 0 KG8N, and discussed previously                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254418 - with Doctor Lee during the meeting on 181127 0800. ref SDS R7 OI8F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254420 -  ..
254421 - Have resumed Mylanta on regular schedule.  Further testing indicates                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254422 - taking Mylanta with Calcium Carbonate (Tums) everyday, has not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254423 - increased blood pressure, and the combination provides better                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254424 - digestion support.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254426 -  ..
254427 - Reviewed eating practice - small bites taken with liquid, and mixing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254428 - meat products with other food enables each bite to slip past small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254429 - opening of LESV until next EGD dilates again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254431 -  ..
254432 - Estimated LESV will engage today at 19 mm, since difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254433 - swallowing has not occurred this cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254434 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254436 -  ..
2545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2547 - 1028                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2548 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254801 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254802 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254803 - 
254804 - Follow up ref SDS S8 7V6I, ref SDS S4 7V6I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254806 - Wheeled into procedure room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254808 -  ..
254809 - Mimi was the nurse for the procedure.  She was training a new nurse,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254810 - also named Mimi.  They connected sensors to monitor vitals.  She                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254811 - connected IV to saline drip, ready to apply conscious sedation drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254813 -  ..
254814 - Everything went smoothly in the OR today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254816 -  ..
254817 - Mimi gave standard amount of lidocaine sprayed into the mouth.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254819 -  ..
254820 - Lara applied conscious sedation using the catheter, which Danis set                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254821 - earlier in Preparation, per above. ref SDS S8 JA4N  Understandings were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254822 - applied on sedation protocol reviewed with Doctor Lee and agreed in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254823 - signing the consent, per above. ref SDS S4 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254825 -  ..
254826 - Danta was the technical assistant today.  Did a great job as always.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254828 -  ..
254829 - The team then did the EDG/dilation procedure with Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254831 -  ..
254832 - Gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254833 - Time Out............. 0856                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254834 - Procedure Start...... 0845                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254836 -  ..
254837 - Total time for procedure...... 11 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254838 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254839 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254840 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254841 -            [...below Progress Notes say Procedure ended at 0850, for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254842 -            total gastroscope time 10 minutes. ref SDS S4 LS3F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254843 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254844 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254845 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254847 -  ..
254848 - LESV Contract 2 MM Dilation 20 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254849 - Meeting Doctor Lee Present Results EGD Dilation Procedure 20 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254850 - Results EGD Dilation Procedure Meeting Doctor Lee Present 20 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254851 - Liquid Diet Continue LESV Contracted 6 MM Worst in Patient History                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254852 - 
254853 - Follow up ref SDS S8 5H5J, ref SDS S4 5H5J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254855 -  ..
2549 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2550 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2551 - 0945                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2552 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255201 - Woke in recovery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
255203 -  ..
255204 - Before the doctor arrived for discussion, requested copy of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
255205 - handwritten report on drugs administered during procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
255207 -  ..
255208 - Post Procedure Record unclear on volume ML normal saline infused.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
255209 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255210 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255211 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255213 -  ..
255214 - Post Procedure Care Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
255215 - Patient received in Recovery 0856 and woke at 0910.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255216 - Blood pressure 110/74 to 139/74  Heart Rate 69 - 76                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255217 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255218 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255219 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255221 -  ..
255222 - Nursing Procedural Sedation & Analgesia Flow Sheet Record - Page 1 of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
255223 - Versed total.............   3 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255224 - Fentanyl total........... 150 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255225 - Benadryl.................  50 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255226 - Lidocaine................   _ ML - likely 1 - 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255227 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255228 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255230 -  ..
255231 - Triamcinalone not reported, as it is for prior procedure on 181127                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255232 - 0800. ref SDS R7 CR4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
255234 -  ..
255235 - Doctor Lee reported good results again today.  He was concerned about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255236 - finding small amount of ulceration on side of esophagus above LESV,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255238 -  ..
255239 - Seems different from prior severe ulceration on top of LESV, reprted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255240 - on 160816 0800, ref SDS I2 RZ3G,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255242 -               ..
255243 -              F:\05\00003\SM\CC\AGMJ\20190215-080000\MAC00029033884.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255245 -  ..
255246 - LESV contracted from 20 mm down to 19 mm, showing continuing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
255247 - improvement compared to severe weekly contractions last year, evident                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255248 - from case study below. ref SDS S4 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
255250 -  ..
255251 - Doctor Lee dilated LESV opening from 18 to 20 mm, as discussed during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255252 - the meeting this morning, above. ref SDS S4 FN6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255254 -  ..
255255 - Versed was limited today, to 3 ml, as discussed during the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255256 - before the procedure, per above. ref SDS S4 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255258 -  ..
255259 - The doctor indicated the current medication and eating regimens, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255260 - above, ref SDS 0 PD5F, have resolved prior achalasia difficulties,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255261 - i.e., work today demonstrated strong response to treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
255262 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255263 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255264 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255265 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2553 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 S8 XM3J, ref SDS S4 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 -          1     190319   40  160     19     20......0.0.....3......50......150.....10.... ref SDS S8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260418 -          1     190215   40  160     19     20......0.0.....3......50......150.....10.... ref SDS S4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260419 -          1     190118   40  160     18     20......0.0.....3......50......150.....10.... ref SDS R8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260420 -          1     181218   40  160     18     20......0.0.....4......50......150.....10.... ref SDS R8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260421 -          1     181127   40  160     18     20......0.0.....3......25......250.....10.... ref SDS R7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260422 -          1     181030   40  160     18     20......0.0.....3......25......250.....10.... ref SDS R6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260423 -          1     181002   40  160     18     20......0.0.....3......25......250.....10.... ref SDS R5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260424 -          1     180904   40  160     16.5   19......0.0.....3......25......250.....10.... ref SDS R2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260425 -          1     180814   40  160     16     19......0.0.....3......25......250.....10.... ref SDS R0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260426 -          0.5   180713   40  160     16.5   18......0.0.....3......25......250.....10.... ref SDS Q7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260427 -          2.5   180627   40  160     12     16.5....0.0.....3......25......250.....10.... ref SDS Q5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260428 -          2     180417   40  160     16.5   19......1.0.....3......25......250.....10.... ref SDS P6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260429 -          1.50  180227   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260430 -          1.25  180109   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260431 -          1     171128   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS O7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260432 -          2     171031   40  160     15.5   18......1.0.....4......25......250.....10.... ref SDS O3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260433 -          1.53  170905   80   80     15     18......1.0.....3......25......250.....10.... ref SDS N9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260434 -          1.53  170516   80   80     16.5   19......1.0.....5......25......250.....10.... ref SDS N4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260435 -          1.53  170404   80   80     16.5   18......1.5.....5......25......200.....10.... ref SDS M8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260436 -          1.53  170221   80   80     15     18......2.0.....5......25......200......5.... ref SDS M2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260437 -          0.80  170106   80   80     16.5   18......2.0.....5......25......200......5.... ref SDS L6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260438 -          0.23  161213   80   80     15     18......3.0.....5......25......200......5.... ref SDS L0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260439 -          0.20  161206   80   80     11     16.5....1.0.....5......25......200......5.... ref SDS K6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260440 -          0.27  161130   80   80     11     15......0.0.....5......25......200......5.... ref SDS K3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260441 -          0.23  161122   80   80      6     12......0.0.....5......25......200......5.... ref SDS K1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260442 -          1.40  161115   42   80     10     10......0.0.....5......25......200......5.... ref SDS J7 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260443 -          0.83  161004   26   80     11     15......5.0.....5......25......200......5.... ref SDS J1 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260444 -     *1   0.80  160909   80    0     10     15......5.0.....5......25......200......5.... ref SDS I7 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260445 -          2     160816   11   40      9.5   10......5.0.....4......50......150......5.... ref SDS I1 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260446 -          3     160617   10   40      9.5   15......5.0.....6......50......250......5.... ref SDS G9 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260447 -     *2   3     160315   15   40      9.5   15......3.0.....5......25......250......5.... ref SDS G7 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260448 -          8     151204   32   20     10     15......5.0.....5......25......200......5.... ref SDS F3 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260449 -     *3   6     150421   41          16.5   18......3.0.....4......50......250......5.... ref SDS D3 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260450 -          6     141107   37          15     18......4.0.....5......50......150......5.... ref SDS C4 E54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260451 -          6     140509   24          16.5   18..............5......50......200......5.... ref SDS B4 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260452 -     *4   7     131115   24          16.5   18......2.0.....4......50......200......5.... ref SDS A6 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260453 -          3     130416   38          18     18......2.0.....5......50......250......5.... ref SDS A0 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260454 -          4     130110   39          15     18......3.0.....4......50......100......5.... ref SDS 95 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260455 -     *5   6     120925   38          15     18......4.0.....5......50......200......5.... ref SDS 87 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260456 -     *6   4     120322   27          16.5   18..............4......50......150......5.... ref SDS 84 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260457 -     *7   3     111115   76          16.5   18..............4......50......200......5.... ref SDS 81 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260458 -          4     110819   80          15     16.5....2.5.....5......50......200......5.... ref SDS 80 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260459 -          2     110429   80          13     16.5....3.5.....5..............200......5.... ref SDS 75 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260460 -          2     110218   80          11     14......2.0.....4......50......150......5.... ref SDS 71 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260461 -          4     101210   40          11     14......................................5.... ref SDS 66 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260462 -          6     100827    4          11     15..............5......50......250......5.... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260463 -          3     100305    0          11     15..............5......50......250......5.... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260464 -          -     091216               Heller Myotomy Fundoplication................. ref SDS 36 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260466 -         ..
260467 -     ** Dates are from case study on exercise, diet, vitals and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260468 -        medication, shown on 160101, ref SDS G0 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260469 -        previously on 140101. ref SDS A9 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260470 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260471 -     *1 On 160911 paused Pantoprazole to reduce dehydration through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260472 -        frequent urination until after Half Dome, and resumed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260473 -        160920.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260474 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260475 -     *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS A9 E64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260476 -        Resumed Omeprazole 20 mg on 160323. ref SDS G0 RSXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260478 -         ..
260479 -        On 150924 hospitalized hematoma debridement; begin Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260480 -        20 mg per day. ref SDS A9 JT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260481 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260482 -     *3 On 150920 about 5 attacks convulsions, nausea not taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260483 -        Omeprazole - took 40 mg. ref SDS A9 656M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260484 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260485 -     *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260486 -        20 mg for next 5 months. ref SDS A6 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260488 -         ..
260489 -     *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260490 -        20 mg per day, shown in case study on 120101 0900, ref SDS 83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260491 -        AD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260492 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260493 -     *6 On 120907 Doctor Egan research found Omeprazole increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260494 -        blood pressure, sensed possible correlation patient sudden                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260495 -        rise in blood pressure, recommended reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260496 -        to 20 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260497 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260498 -     *7 On 11115 Doctor Lee prescribed continue PPM 80 mg; on 111201,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260499 -        patient reduced dose to 20 mg on record of rising blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260500 -        pressure despite increased hiking; research indicated PPI may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260501 -        elevate blood pressure, see case study 101010 0744, ref SDS 57 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260508 -  ..
260509 - Conscious Sedation Reduced Dose Applied for 16 Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260510 - 
260511 - Follow up ref SDS S8 714N, ref SDS S4 714N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260512 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260513 - Nursing Procedural Sedation & Analgesia Flow Sheet Record Page 1 shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260514 - versed 3 ML.  Since procedure only took 12 minutes, ref SDS S4 Q65I,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260515 - the doctor was able to minimize exposure to versed, which previously                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260516 - caused stroke symptoms with 6 ml, as occurred on 160617 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260517 - ref SDS G9 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260519 -  ..
260520 - No post procedure side effects as occurred on 161213 0800. ref SDS L0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260521 - R74J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260523 -  ..
260524 - Seem sleepy though even hours after the procedure using 3 ml versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260525 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260527 -  ..
260528 - Ulceration Recurred on Esophagus Above LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260529 - 
260530 - Follow up ref SDS S8 RZ3G, ref SDS S4 RZ3G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260532 - Doctor Lee reported this morning that EGD procedure found new, minor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260533 - ulceration on side of esophagus a distance above LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260535 -  ..
260536 - Doctor Lee did not have time to present pictures showing improved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260537 - condition with reduced ulceration of LESV, following EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260538 - procedure today, per above. ref SDS S4 GD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260540 -  ..
260541 - Pictures from procedure were later received on 190316...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260543 -              F:\05\00003\SM\CC\AGMJ\20190215-080000\MAC00029033884.pdf
260544 -  ..
260545 - This is first recurrent of ulceration since severe ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260546 - condition that occurred adjacent to LESV opening found during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260547 - procedure on 161115 0800. ref SDS J7 K44N  The prior ulceration found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260548 - during EGD procedure on 161122 1245, ref SDS K0 RZ3G, are still no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260549 - longer visible.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260551 -  ..
260552 - Since ulceration found today, was above LESV, Doctor Lee advised that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260553 - he was able to dilate LESV from 19 - 20mm, shown in the table above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260554 - ref SDS S8 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260556 -  ..
260557 - We reviewed the record indicating that prior ulceration occurred from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260558 - taking 2 naproxen during hiking and without liquid, i.e., water.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260560 -  ..
260561 - Normally only take 1 naproxen pill before hiking.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260563 -  ..
260564 - Doctor Lee proposed taking only 1 naproxen pill at a time, and washing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260565 - it down with generous amout of liquid, e.g. water, or Coco Cola.  Then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260566 - take a 2nd pill if needed separately with more liquid.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260568 -  ..
260569 - He asked if naproxen pills can be cut in half to further increase                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260570 - potential for the pills to pass through LESV?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260572 -  ..
260573 - Will investigate with VA Pharmacy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260575 -  ..
260576 - Also discussed cutting hydrocodone pills (actually Norco that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260577 - combines hydrocone with acetamine) can be cut in half?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260579 -  ..
260580 - Will investigate with VA Pharmacy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260582 -  ..
260583 - After we do next PRP, will not need any pain medication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260584 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260585 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260586 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260588 -  ..
260589 - Schedule Next Procedure and Post Procedure Review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260590 - 
260591 - Follow up ref SDS S8 XF6X, ref SDS S4 XF6X.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260592 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260593 - Next procedure is scheduled on 190319 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260595 -  ..
260596 - Plan to meet on 190228 1000, for consultation on case management per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260597 - discussion this morning, see above. ref SDS S4 ZU5J  The meeting was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260598 - scheduled by Sonja on 190118 0800. ref SDS S1 JJ9O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260599 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260600 -            [On 190228 1000 met with Doctor Lee to discuss case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260601 -            progress. ref SDS S5 KB6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260602 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2703 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270401 -  ..
270402 - Progress Notes Release of Information ROI CD Contents Received on 190316                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270403 - 
270404 - Follow up ref SDS S8 Q05K, ref SDS S4 Q05K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270406 -  ..
270407 - Request records on CD from ROI for this medical encounter due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270408 - continual difficulties downloading medical records from VA website                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270409 - at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270410 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270411 -              https://www.myhealth.va.gov/mhv-portal-web/track-health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270412 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270419 -  ..
270420 - On 190510 1720 Kathy delivered CD with progress notes, obtained from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270421 - ROI yesterday.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270423 -  ..
270424 - Stored Progess Notes for procedure on 190416 at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270425 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270426 -              F:\05\00003\SM\CC\AGMJ\20190416-080000\welch02.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270428 -  ..
270429 - Stored photographs for procedure on 190215 at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270430 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270431 -              F:\05\00003\SM\CC\AGMJ\20190416-080000\MAC00030808070.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270432 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270433 -              F:\05\00003\SM\CC\AGMJ\20190416-080000\MAC00030812228.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270434 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270436 -  ..
270437 - Stored pathology report on biopsy taken at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270438 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270439 -              F:\05\00003\SM\CC\AGMJ\20190416-080000\welch03.txt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270440 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270441 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270442 -    1.  LOCAL TITLE: EGD Procedure Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270443 -        STANDARD TITLE: GASTROENTEROLOGY DIAGNOSTIC STUDY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270444 -        DATE OF NOTE: APR 16, 2019@11:24:04    ENTRY DATE: APR 16, 2019@11:24:04                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270445 -        AUTHOR: CLINICAL,DEVICE PRO  EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270446 -        URGENCY: STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270447 -        *** EGD Procedure Report Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270448 -        ** DOCUMENT IN VISTA IMAGING **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270449 -        SEE FULL REPORT IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270451 -         ..
270452 -        SIGNATURE NOT REQUIRED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270453 -        SEE SIGNATURE IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270454 -        ** (PENTAX EGD)  AUTO-INSTRUMENT DIAGNOSIS **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270456 -         ..
270457 -    2.  Procedure: EGD  UPPER ENDOSCOPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270458 -        PENTAX INSTRUMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270459 -        10535 Hospital Way Mather CA, 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270460 -        EGD PROCEDURE REPORT     EXAM DATE: 04/16/2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270462 -         ..
270465 -        ATTENDING:     Randall Lee, MD     STATUS: outpatient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270466 -        ASSISTING MD:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270467 -        ASSISTANT:      Ann Aguilar, RN and Dontay Phillips, Tech                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270469 -         ..
270470 -    3.  INDICATIONS:  The patient is a 74 yr old male here for an EGD due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270471 -        PROCEDURE PERFORMED:     EGD w/ balloon dilation of esophagus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270472 -        MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270473 -        TOPICAL ANESTHETIC:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270475 -         ..
270476 -    4.  CONSENT:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270478 -         ..
270479 -        The risks, benefits, and alternatives to this procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270480 -        including but not limited to the risks of bleeding and bowel                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270481 -        perforation were explained to the patient.  The patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270482 -        understood and provided written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270484 -         ..
270485 -    5.  DESCRIPTION OF PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270486 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270487 -        In the Sacramento VA GI Endoscopy Unit,  Informed consent was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270488 -        verified, confirmed and timeout was performed.  The patient was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270489 -        placed in left lateral decubitus position.  Oxygen was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270490 -        administered.  Continuous oximetric and hemodynamic monitoring                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270491 -        was initiated.  Intravenous sedation was administered in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270492 -        divided doses.  After a bite block was placed in the patient's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270493 -        mouth,  the GIF-HQ190 2854149 videoscope was introduced under                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270494 -        direct vision through the mouth and advanced to the   .                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270495 -        The stomach and esophagus were decompressed, and the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270496 -        gastroscope removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270498 -         ..
270499 -    6.  ADVERSE EVENTS:     There were no complications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270501 -         ..
270502 -    7.  IMPRESSIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270503 -        RECOMMENDATIONS:     image report.  see egd dictated 22681                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270504 -        for details.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270506 -         ..
270507 -    8.  GE junction stenosis TTS balloon dilated 18-19-20mm. injected                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270508 -        with triamcinolone 0.5ml x4. biopsied.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270510 -         ..
270511 -    9.  REPEAT EXAM:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270512 -        ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270513 -        Randall Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270514 -        eSigned: Randall Lee, MD 4/16/2019 11:23:55 AM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270515 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270516 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270518 -         ..
270519 -    1.  PATIENT NAME:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270523 -         ..
270524 -        Administrative Closure: 04/16/2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270525 -        by: CLINICAL,DEVICE PROXY SERVICE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270527 -        04/16/2019 ADDENDUM                      STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270531 -         ..
270532 -    2.  NAME OF PROCEDURES:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270534 -        1.  Esophagogastroduodenoscopy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270535 -        2.  Through-the-scope (TTS) balloon dilation of esophageal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270536 -            stricture.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270537 -        3.  Endoscopic injection.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270538 -        4.  Endoscopic biopsy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270540 -         ..
270541 -    3.  ATTENDING PHYSICIAN:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270542 -        Randal E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270544 -         ..
270545 -    4.  INDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270548 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270549 -        74-year-old man who had a laparoscopic myotomy and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270550 -        fundoplication at the San Francisco VA in 2009 for treatment of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270551 -        achalasia.  Subsequently, he developed esophageal reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270552 -        complicated by a stricture that has required repeated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270553 -        endoscopic dilations.  His most recent EGD and dilation were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270554 -        March 19, 2019 at which time his esophagus was dilated from 19                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270555 -        to 20 mm with a TTS balloon.  An associated ulcer was noted at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270556 -        that particular is stricture.  It was thought that this might                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270557 -        have been due to the side effect of naproxen or other                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270558 -        medications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270560 -         ..
270561 -        Since then, he has not used any naproxen or other pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270562 -        medications.  He has not noticed a significant change in his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270563 -        dysphagia.  He continues to be physically very active.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270565 -         ..
270566 -    5.  CONSENT:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270568 -        For the details, please see the associated EndoPRO                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270569 -        report.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270571 -         ..
270572 -    6.  INTRAVENOUS MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270573 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270574 -        1.  Diphenhydramine 50 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270575 -        2.  Fentanyl 200 mcg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270576 -        3.  Midazolam 3 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270578 -         ..
270579 -    7.  PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270580 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270581 -        In the Sacramento VA GI Endoscopy Unit, the patient was placed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270582 -        in the left lateral decubitus position.  Oxygen at 2 liters                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270583 -        per minute by nasal cannula was administered.  Continuous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270584 -        oximetric and hemodynamic monitoring was initiated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270585 -        Intravenous sedation was administered in divided doses.  A                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270586 -        bite block was placed in the patient's mouth, and an Olympus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270587 -        GIF HQ-190 video gastroscope was advanced under direct vision                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270588 -        to the third portion of the duodenum.  Retroflexed views of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270589 -        the incisura, fundus, and cardia were performed.  Retained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270590 -        saliva within the esophagus required irrigation and suctioning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270591 -        for clearance.  A TTS balloon was positioned across the lower                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270592 -        esophageal sphincter and inflated sequentially from 18 to 19                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270593 -        to 20 mm.  The balloon was deflated, withdrawn, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270594 -        re-examination showed 2 shallow mucosal tears around the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270595 -        circumference of the stricture.  The GE junction was biopsied                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270596 -        and labeled specimen A.  Stomach and esophagus were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270597 -        decompressed and the gastroscope removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270599 -         ..
270600 -    8.  COMPLICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270601 -        None immediate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270603 -         ..
270604 -    9.  FINDINGS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270606 -        1.  Proximal and mid-esophageal body dilated and without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270607 -            noticeable peristaltic waves.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270609 -        2.  GE junction stricture again noted at 39 cm, with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270610 -            associated shallow ulcer.  Based on sizing with a TTS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270611 -            balloon, the initial diameter appears to be 18 mm. 3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270613 -             ..
270614 -        3.  Gastric fundus appearance consistent with prior history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270615 -            fundoplication with relaxation and prolapse of gastric                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270616 -            mucosa in the distal esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270618 -             ..
270619 -        4.  Diaphragm level noted at approximately 41 cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270621 -             ..
270622 -        5.  Normal gastric mucosa in the fundus and body.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270624 -             ..
270625 -        6.  Patchy gastric mucosal erythema in the antrum again noted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270626 -            without erosion, ulceration, or mass effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270628 -             ..
270629 -        7.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270631 -             ..
270632 -        8.  Normal duodenum to D3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270633 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270635 -         ..
270636 -   10.  IMPRESSION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270637 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270638 -        1.  Distal esophageal stricture secondary to acid reflux.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270639 -            luminal size appears decreased down to 18 mm based on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270640 -            sizing with the balloon.  The presence of the persistent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270641 -            ulceration now suggests ineffective acid suppression                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270642 -            rather than side effect of medications.  Note that his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270643 -            current regimen is famotidine 80 mg in the morning plus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270644 -            famotidine 80 mg alternating with pantoprazole 40 mg in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270645 -            the evening followed by a bedtime dose of famotidine 80 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270646 -            plus Mylanta 40 mL plus calcium carbonate 1000 mg.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270647 -            regimen was selected to reduce the subjective side effect                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270648 -            of pantoprazole, which the patient experiences as frequent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270649 -            urination and foot dysesthesia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270651 -  ..
270652 - Patient further experiences very dry mouth at night, waking from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270653 - sleep.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270655 -  ..
270656 - Impressions continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270657 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270658 -        2.  Esophageal body appearance consistent with known diagnosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270659 -            of achalasia without evidence of mass effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270661 -             ..
270662 -        3.  Gastric fundus appearance again consistent with known                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270663 -            history of fundoplication relaxation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270665 -         ..
270666 -   11.  RECOMMENDATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270667 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270668 -        1.  Consideration of boosting pantoprazole back to 40 mg once                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270669 -            daily.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270671 -             ..
270672 -        2.  Repeat EGD and dilation as currently scheduled in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270673 -            approximately 46 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270675 -         ..
270676 -   12.  DISPOSITION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270677 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270678 -        1.  Patient was observed in Recovery Room and then discharged                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270679 -            to home with a companion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270680 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270681 -        2.  I have reviewed the endoscopic findings with the patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270682 -            prior to discharge.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270683 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270685 -         ..
270686 -   13.  TIME START: 1044 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270687 -        TIME END: 1103 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270689 -         ..
270690 -        D:  4/16/2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270691 -        T:  4/16/2019 Job number:  22681                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270692 -        DMC/AP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270693 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270695 -         ..
270696 -        Microscopic exam/diagnosis: (Date Spec taken: Apr 16, 2019)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270697 -        GASTROESOPHAGEAL JUNCTION, AT 39 CM (BIOPSY): INFLAMED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270698 -        SQUAMOCOLUMNAR MUCOSA WITH FIBRINOPURULENT EXUDATE CONSISTENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270699 -        WITH ULCER                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270700 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270701 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270703 -  ..
270704 - BIOPSY Pathology Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270705 - 
270706 - Stored pathology report on biopsy taken at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270707 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270708 -              F:\05\00003\SM\CC\AGMJ\20190416-080000\welch03.txt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270709 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270710 -    1.  Type of Report:       Surgical Pathology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270711 -        Specimen:             GE JUNCTION AT 39 CM BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270712 -        Date Obtained:        16 Apr 2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270713 -        Performing Location:  No CA Healthcare Sys-Martinez150 Muir                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270714 -        Road, MARTINEZ 94553                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270715 -        Date Completed:       22 Apr 2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270717 -         ..
270718 -        SURGICAL PATHOLOGY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270720 -         ..
270721 -        Reporting Lab: SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270722 -                       10535 HOSPITAL WAY MATHER, CA 95655-4200                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270724 -         ..
270725 -    2.  Date Spec taken: Apr 16, 2019        Pathologist:MARY MEIGHAN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270726 -        TOMIC MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270727 -        Date Spec rec'd: Apr 18, 2019 10:31  Resident: YING LIU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270728 -        Date  completed: Apr 22, 2019        Accession #: SP 19 3158                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270729 -        Submitted by:                        Practitioner:RANDALL E LEE MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270731 -         ..
270732 -    3.  Specimen:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270733 -        GE JUNCTION AT 39 CM BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270734 -        Brief Clinical History:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270735 -        SURVEILLANCE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270736 -        Preoperative Diagnosis:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270737 -        74 Y/O MALE WITH GERD STRICTURE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270738 -        Operative Findings:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270739 -        EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270741 -         ..
270742 -    4.  Postoperative Diagnosis:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270743 -        BENIGN-APPEARING ESOPHAGEAL STRICTURE AT GE JUNCTION 39CM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270745 -         ..
270746 -    5.  Gross description:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270747 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270748 -        Received in formalin with proper patient identification labeled "GE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270749 -        junction at 39 cm" are multiple fragments of tan-grey tissue measuring                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270750 -        0.4 x 0.3 x 0.2 cm in aggregate. Totally submitted in one cassette.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270751 -        (YL 4/18/2019 12:47 PM)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270753 -         ..
270754 -    6.  Microscopic exam/diagnosis: (Date Spec taken: Apr 16, 2019)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270755 -        GASTROESOPHAGEAL JUNCTION, AT 39 CM (BIOPSY): INFLAMED SQUAMOCOLUMNAR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270756 -        MUCOSA WITH FIBRINOPURULENT EXUDATE CONSISTENT WITH ULCER                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270758 -         ..
270759 -    7.  COMMENT: PAS-F stain is negative for fungal organisms.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270761 -         ..
270762 -    8.  Performing Laboratory:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270763 -        Surgical Pathology Report Performed By:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270764 -        SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270765 -        10535 HOSPITAL WAY MATHER, CA 95655-4200                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270766 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270767 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270768 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270769 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270770 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270771 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270772 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270773 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270774 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270775 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270776 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270777 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270778 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2708 -