CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2503 -    ..
2504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
2505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250501 - Follow up ref SDS U4 0000. ref SDS U0 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 190521. ref SDS U4 VV6N  Reported increased digestion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250510 - difficulties, waking up choking on aspirated reflux - may relate to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250511 - continuing relaxation Dor fundoplication, required taking Baking Soda.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250512 - ref SDS U4 N27F  Doctor Lee ordered increased Mylanta to replace baking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250513 - soda for future episodes. ref SDS U4 8468  Reviewed pending issues,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250514 - including frequent urination taking Pantoprazole every day, causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250515 - dehydration. ref SDS U4 UI5N  Approval to cut or crush naproxen and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250516 - hydrocodone pills into smaller size to prevent buildup above                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250517 - contracted LESV. ref SDS U4 LL4K  Signed blank consent for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250518 - procedure today, on assurance that stroke symptoms following prior EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250519 - on 160617, with mild recurrence on 161213, would not occur.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250520 - ref SDS U4 639M  EGD dilation procedure went smoothly, with no reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250521 - of difficulties. ref SDS U4 7V6I  Gastroscope in and out took 11                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250522 - minutes. ref SDS U4 UT4N  Versed sedation medication required only 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250523 - mg, well below 6 mg that caused prior stroke symptoms. ref SDS U4 CR4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250524 - Post procedure Doctor Lee reported good results with LESV contracting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250525 - to only 19 mm, so he was able to dilate LESV back to 20 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250526 - ref SDS U4 GD5K  Ulceration significantly resolved over past 4 weeks,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250527 - which enabled the doctor to dilate LESV needed for better swallowing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250528 - ref SDS U4 RZ3G  Continued improvement in ulceration and LESV dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250529 - shows good response to treatment with prescribed medications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250530 - ref SDS U4 JK6N  Scheduled next EGD dilation in 4 weeks on 190709 0730.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250531 - ref SDS U4 XF6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250537 -  ..
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 K3 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 K6 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 P8 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 Q1 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 R7 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 U4 NU8L, ref SDS U0 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 R1 RE9L  The GI Clinic changed procedures, so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251809 - Jessica issued new schedule for a year ahead, reported in a meeting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251810 - 190416 0800, ref SDS T5 5K7H, and showing EGD dilation today, about 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251811 - weeks after prior procedure on 190618 0730. ref SDS U4 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251813 -  ..
251814 - Applied pre-proc requirements for NPO after midnight, from letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251815 - 101015 1547. ref SDS 58 4J9L  Last food was at......                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251816 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251817 -                         190708 1740                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251819 -  ..
251820 - Drove to Sacramento from Concord on Monday, and stayed at Kathy's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251821 - house about 3 miles from VAMC Sacramento.  Yesterday, paid bills and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251822 - cleaned c21 and c22.  Worked with Mia on tennis.  This morning drove                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251823 - to the VA for EGD treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251824 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251825 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251827 -  ..
2519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2521 - 0655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252201 - Arrived at VAMC Sacramento.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252202 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252203 - Said good morning to Danis walking from parking lot into the hospital.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252204 - Said I missed seeing her last month.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252206 -  ..
252207 - Sonja did check-in to GI Department at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252208 - the customer counter.  She was as usual enthusiastic and helpful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252210 -  ..
252211 - Rosie did vitals.  Nice to see her back on the job after medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252212 - leave.  She is working part time now.  In June she went to Lake Shasta                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252213 - with her husband and son for a vacation.  Had a good time.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252214 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252216 -  ..
252217 - Vitals were taken today, and found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252218 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252219 -            Weight.................. 186                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252220 -            BP...................... 139 63                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252221 -            HR (pulse).............. 56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252222 -            Oxygen.................. 96                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252223 -            Temp.................... 97.9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252224 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252226 -  ..
252227 - Kathy cell phone for designated driver...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252231 -  ..
252232 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252233 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252234 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252235 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252236 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252237 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252238 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252240 -  ..
2523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2525 - 0730                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252601 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252602 - 
252603 - Follow up ref SDS U4 EP75, ref SDS U0 EP75.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252605 - No objections nor concerns today, as occurred previously on 161115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252606 - 0800, ref SDS J8 WA5I, and again on 161130 1038. ref SDS K4 EP75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252608 -  ..
252609 - Saw Jennifer and said hello.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252611 -  ..
252612 - Did not see Clair today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252614 -  ..
252615 - In the GI Clinic, Gracie directed me to a gurney.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252617 -  ..
252618 - Hazel did initial patient setup.  Most information entered today for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252619 - patient identification and medical history was the same.  Today, she                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252620 - asked more questions.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252622 -  ..
252623 - She asked about pain?  Reported level 0.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252625 -  ..
252626 - Grace set catheter IV for sedation.  Did 10 pushups with feet on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252627 - gurney to improve blood flow.  Grace was successful on 1st stick in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252628 - right inner arm left side elbow; 1st stick was pain level 5.  Veins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252629 - develop adhesions (scar tissue) that take time to heal, and prevent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252630 - blood flow into the IV needle.  This morning ran hot water on right                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252631 - forearm in the shower to dilate veins, which helped with pushups to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252632 - get blood flow on 1 stick today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252634 -  ..
252635 - Case study on sticks required to set catheter is reported on 110429                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252636 - 1230. ref SDS 76 UO3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252638 -  ..
252639 - Hazel is the nurse in the room today.  She set blood pressure cuff                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252640 - and EKG probes.  They will be connected to equipment that monitors                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252641 - vitals during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252643 -  ..
252644 - Complimented the team saying they work well together, like a pit stop                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252645 - crew at the Indianopolis 500.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252647 -  ..
252648 - Asked Hazel about writing letter to complement management on providing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252649 - effective and efficient medical care.  Previously, commended work in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252650 - GI Clinic with letter to director of the hospital on 161208 2239.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252651 - ref SDS K9 918K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252653 -  ..
252654 - Several nurses said VA management has been claiming the nurses are not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252655 - working hard enough, and so are making changes to increase efficiency                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252656 - of GI medical services.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252658 -  ..
252659 - Doctor Lee said send the letter to Chief of GI, Doctor Leung.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252660 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252661 -                    Department of Veterans Affairs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252662 -                    Northern California Health Care System                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252663 -                    Gastroenterology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252664 -                    Doctor Joseph W Leung, Chief                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252665 -                    10535 Hospital Way                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252666 -                    Building 645                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252667 -                    Mather, CA 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252668 -                    916 366 5339                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252670 -             ..
252671 -            [On 190719 1252 letter to Doctor Leung commends efficient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252672 -            medical care by nurses. ref SDS V0 FO38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252674 -             ..
252675 -            [On 190813 0730 during setup for EGD procedure, nurses said                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252676 -            they were not aware of the letter commending excellent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252677 -            work. ref SDS V1 VM8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252679 -  ..
252680 - There is a new procedure today.  Wheeled into OR before meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252681 - Doctor Lee to review issues and sign consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252682 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252683 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252684 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252685 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252686 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252688 -  ..
2527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2529 - 0740                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253001 - Meeting Doctor Lee and Consent for Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253002 - 
253003 - Follow up ref SDS U4 GG6G, ref SDS U0 GG6G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253004 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253005 - Doctor Lee asked questions on patient history to verify ready for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253006 - procedure, e.g., no allergies, and NPO after midnight to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253007 - conflicts with anesthesia; no health problems, e.g., no diabetes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253008 - alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253010 -  ..
253011 - Doctor Lee asked about medication protocol?  Reported protocol he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253012 - prescribed after prior EGD on 190416 1000. ref SDS T6 JK6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253014 -  ..
253015 - This morning he confirmed the following prescription...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253016 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253017 -        Famotidine............... 2 40mg pills in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253018 -        Pantoprazole............. 1 40mg pill 30 min before dinner every day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253019 -        Mylanta.................. 40 ml OA 2200 - 1 hour after statins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253020 -        Calcium Carb (Tums)...... 2 500mg pills 30 min after Mylanta                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253021 -        Famotidine............... 2 40mg pills before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253023 -  ..
253024 - Eating regimen is shown in case study of daily diet, medication,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253025 - exercise and vitals, reported on 190101 0730. ref SDS S6 QJ5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253026 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253027 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253028 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253029 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253031 -  ..
2531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2533 - 0815                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253401 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253402 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253403 - 
253404 - Follow up ref SDS U4 KT9M, ref SDS U0 KT9M.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253406 - Doctor Lee presented a digital tablet and requested signature to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253407 - consent for the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253409 -  ..
253410 - Noted that signature is entered on completely black screen, required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253411 - without reading online documents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253413 -  ..
253414 - Advised that signature is based on following understandings...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253416 -         ..
253417 -    1.  Calcium Carbonate (Tums) ordered refill on 190623 0808.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253418 -        ref SDS U5 4G4N  On 190707, Post Office reports package was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253419 -        delivered on 190707 0901. ref SDS U8 4G4N  This indicates                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253420 -        delivery error.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253421 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253422 -            [On 190714 1558 Calcium Carbonate was delivered at front                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253423 -            door on return from trip to Oregon, ref SDS U9 4G4N; this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253424 -            indicates Doctor Lee took immediate action to recover from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253425 -            post office error reporting package was delivered on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253426 -            190528, when in fact it was not, reported on 190707 0901,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253427 -            ref SDS U8 6H6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253428 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253430 -         ..
253431 -    2.  Frequent urination seems stabalized at rate that minimizes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253432 -        dehydration, see case study on 190101 0730. ref SDS S6 TTTQ                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253434 -         ..
253435 -        Dehydration shown by feet indicating increased dryness                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253437 -  ..
253438 - The doctor reviewed the study showing increased urination beginning on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253439 - 190416, following the prescription taking Pentoprazole 40 mg everyday.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253440 - ref SDS S6 YY7N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253442 -  ..
253443 - Doctor Lee removed socks to examine feet.  He commented they are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253444 - Smartwool socks, which he was also wearing today.  Explained that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253445 - Doctor Thuillier at VAMCSF Orthopedics Department recommended Smartool                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253446 - socks to complement Hoka Bondi 5 shoes, for preventing feet blisters                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253447 - when hiking long distances, reported on 180425 1145. ref SDS Q3 WW8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253448 - They have been very effective, shown by hike on 190602 in case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253449 - on exercise, vitals, medication and diet in the record on 190101 0730.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253450 - ref SDS S6 PTSS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253452 -  ..
253453 - Doctor Lee noted both feet are...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253454 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253456 -         ..
253457 -    3.  Voice less scratchy following examination and recommendations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253458 -        by Doctor Lee during prior EGD procedure on 181218 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253459 -        ref SDS S4 RX8I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253461 -         ..
253462 -        Voice better concentrating on washing throat with carbonated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253463 -        beverage after each bite of food during meals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253465 -         ..
253466 -        Voice also better after recent increase dilating LESV to 20 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253467 -        has improved swallowing, compared to prior practice dilating to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253468 -        only 18 mm.  This has also improved voice function.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253470 -  ..
253471 - Asked Hazel about my voice today.  She said voice seems a little off                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253472 - this morning.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253474 -  ..
253475 - Doctor Lee concurred voice better this morning than it has been in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253476 - the past, but still a "little off."                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253477 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253478 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253479 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253480 -    4.  Ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253481 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253482 -        Shown in photographs taken on 190618, ref SDS U4 W35I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253483 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253484 -              F:\05\00003\SM\CC\AGMJ\20190618-073000\MAC00032602751.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253486 -         ..
253487 -        On 190416 0800 Doctor Lee pointed to "white" area that appears                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253488 -        protruding on the right side of image 5, ref SDS T6 C18L, as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253489 -        showing evidence of ulceration found during prior EGD on 190319                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253490 -        0800. ref SDS T4 RZ3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253492 -         ..
253493 -        Stopped pain medication on 190317, shown in case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253494 -        190101 0730. ref SDS S6 PWYS  However, had to increase pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253495 -        medication on 190527.  This was stopped again after PRP on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253496 -        190612.  Since then pain medication has mostly been hydrocodone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253497 -        which does not cause ulceration. ref SDS S6 H69K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253499 -         ..
253500 -        Where is ulceration in photograph for EGD on 190618...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253502 -         ..
253503 -        Looks like image #010 may show new ulcerations...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253505 -              F:\05\00003\SM\CC\AGMJ\20190618-073000\MAC00032602751.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253507 -  ..
253508 - Doctor Lee showed where ulceration is recovering in several images.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253510 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253512 -         ..
253513 -    5.  Fundoplication failing, causing continual stricture of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253514 -        requiring frequent dilation.  Doctor planned to research this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253515 -        issue during meeting on 171115 1142. ref SDS O7 XA4F  Discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253516 -        again during meeting on 180124 1130. ref SDS P5 CT56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253518 -         ..
253519 -        On 180627 1300 Doctor Patel seemed to say GI Clinic at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253520 -        has investigated viability of gastroscope fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253521 -        procedures.  He seemed to further advise that the clinic has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253522 -        referred patients for gastroscope full fundoplication, but not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253523 -        to repair fundoplication. ref SDS Q9 JX9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253525 -         ..
253526 -        We reviewed the record in this case that Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253527 -        performed Dor fundoplication on on 091216, as shown Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253528 -        Notes received on 100928 0706. ref SDS 56 VK8F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253530 -         ..
253531 -        At tht time on 180627 1300 asked Doctor Patel to review with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253532 -        the GI team prospects to repair Dor Fundoplication in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253533 -        reduced reflux that continually causes stricture that closes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253534 -        down LESV, requiring repeated EGD dilations on close intervals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253535 -        ref SDS Q9 HP4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253537 -         ..
253538 -        Discuss with Samantha Southi developing proposal for using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253539 -        gastroscope to reposition Dor fundoplication for enhanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253540 -        reflux control.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253542 -  ..
253543 - Did not discuss today, because seem to be managing reflux well enough                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253544 - to minimize formation of stricutre, so that swallowing is not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253545 - impaired, thus avoiding vomiting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253547 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253549 -         ..
253550 -    6.  Hiatal Hernia - can this subside or otherwise improve over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253551 -        time with any action by patient, similar to ulceration of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253552 -        recovering by ending naproxen, and adding carbonated beverage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253553 -        to washout esophagus during meals?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253555 -         ..
253556 -        What drives worsening of hiatal hernia?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253558 -  ..
253559 - Did not discuss this today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253560 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253561 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253563 -         ..
253564 -    7.  Dilation 19 - 20 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253566 -         ..
253567 -        Assess today, toward maintaining reduced medication dose, or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253568 -        increase dose on findings of ulceration LESV recurrance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253570 -  ..
253571 - Today, Doctor Lee dilated LESV from 19/20 to 20 mm, shown in Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253572 - Notes received on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253573 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253574 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253576 -         ..
253577 -    8.  Conscious Sedation with versed - asked Doctor Lee to limit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253578 -        injection of versed to 3 mg, if feasible, and in no case do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253579 -        exceed 5 mg, in order to avoid stroke symptoms on 160617 1637,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253580 -        ref SDS H0 5F6F, following EGD earlier that day when procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253581 -        took 30 minutes, 100% longer, and so versed was increased to 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253582 -        mg, reported on 160617 0800, ref SDS G9 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253584 -  ..
253585 - This was discussed with Doctor Lee, and with Hazel, who will be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253586 - administering drugs, and so this briefing was helpful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253587 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253588 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253589 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253590 -    9.  Barium Swallow Test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253592 -  ..
253593 - Did not discuss today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253594 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253595 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253596 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253597 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253599 -  ..
253600 - Swallowing Has Been Effective Past 4 Weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253601 - 
253602 - Follow up ref SDS U4 VV6N, ref SDS U0 VV6N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253604 - Reported 0 vomiting event past 4 weeks since prior EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253605 - 190521 0930. ref SDS U0 VV6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253607 -  ..
253608 - Doctor Lee glanced through case study on 190101 showing exercise,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253609 - diet, medication and vitals.  He feels record on typical diet and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253610 - eating for example on 190622, aligns with requirments for effective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253611 - swallowing under achalasia, ref SDS S6 STTX; and on 190706.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253612 - ref SDS S6 UVYX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253614 -  ..
253615 - Bubbles clogging LESV seems reduced this cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253617 -  ..
253618 - Burping seems reduced.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253620 -  ..
253621 - Reviewed eating practice - small bites taken with liquid, and mixing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253622 - meat products with other food enables each bite to slip past small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253623 - opening of LESV until next EGD dilates again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253624 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253626 -  ..
253627 - Digestion Deficit Woke Up Choking Aspirated Reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253628 - 
253629 - Follow up ref SDS U4 N27F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253630 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253631 - No aspiration issues this past cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253632 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253633 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253634 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253636 -  ..
2537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2538 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2539 - 0740                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2540 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254001 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254002 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254003 - 
254004 - Follow up ref SDS U4 HE9I, ref SDS U0 HE9I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254006 - Wheeled into procedure room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254008 -  ..
254009 - Hazel was the nurse for the procedure.  She connected sensors to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254010 - monitor vitals.  She connected IV to saline drip, ready to apply                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254011 - conscious sedation drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254013 -  ..
254014 - Everything went smoothly in the OR today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254016 -  ..
254017 - Hazel sprayed lidocaine in the mouth for 10 seconds of gargling.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254019 -  ..
254020 - Hazel applied conscious sedation using the catheter, which Grace set                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254021 - earlier in Preparation, per above. ref SDS 0 JA4N  Understandings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254022 - were applied on sedation protocol reviewed with Doctor Lee and agreed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254023 - in signing the consent, per above. ref SDS 0 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254025 -  ..
254026 - Dante was technical assistant today.  Did a great job as always.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254028 -  ..
254029 - The team then did the EDG/dilation procedure with Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254031 -  ..
254032 - Gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254033 - Start Time........... 0826                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254034 - Procedure Stop....... 0839                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254036 -  ..
254037 - Total time for procedure...... 13 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254039 -  ..
254040 - Nursing Procedural Sedation & Analgesia Flow Sheet Record - Page 1 of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254041 - Versed total................   3 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254042 - Fentanyl total.............. 150 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254043 - Benadryl....................  50 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254044 - Lidocaine...................   5 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254045 - IV Fluids normal saline.....  40 ML  NSIV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254046 - Triamcinalone...............   0 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254048 -  ..
254049 - Blood pressure 163/83 to 115/71  Heart Rate 46 - 59                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254050 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254051 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254052 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254053 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254054 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254055 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254056 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254058 -  ..
254059 - LESV Contract 0 MM Dilation 20 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254060 - Meeting Doctor Lee EGD Dilation 20 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254061 - Ulceration Resolved Meeting Doctor Lee EGD Dilation 20 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254062 - 
254063 - Follow up ref SDS U4 5H5J, ref SDS U0 5H5J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254064 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254065 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2541 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2542 - 0930                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254301 -  ..
254302 - Woke in recovery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254304 -  ..
254305 - Before the doctor arrived for discussion, requested copy of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254306 - handwritten report on drugs administered during procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254308 -  ..
254309 - Post Procedure Care Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254310 - Patient received in Recovery 0910 and woke at 1010.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254311 - Blood pressure 105/63 to 127/69  Heart Rate 43 - 46                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254312 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254313 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254315 -  ..
254316 - Doctor Lee reported very good results today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254318 -  ..
254319 - LESV had minimal if any contraction this cycle, showing continuing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254320 - improvement compared to severe weekly contractions, evident from case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254321 - study below. ref SDS 0 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254323 -  ..
254324 - Doctor Lee explained dilating the baloon to 20 mm.  There was slight                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254325 - bleeding, but no actual breaks in LESV tissue.  This is better than                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254326 - discussed during the meeting this morning, above. ref SDS 0 FN6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254327 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254328 -            [On 190719 1252 letter to Doctor Leung reports great news                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254329 -            that LESV did not contract for 1st time in 6 years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254330 -            ref SDS V0 FN64                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254332 -  ..
254333 - Versed was limited today, to 3 ml, as discussed during the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254334 - before the procedure, per above. ref SDS 0 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254336 -  ..
254337 - The doctor indicated current medication and eating regimens, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254338 - above, ref SDS U4 PD5F, should continue to maintain recovery from prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254339 - achalasia difficulties, i.e., work today demonstrated strong response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254340 - to treatment recovering from esophageal ulceration, including omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254341 - Triamcinalone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254342 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254343 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254344 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254345 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254346 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 U4 XM3J, ref SDS U0 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     190709   40  160     20     20......0.0.....3......50......150.....10.... ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260418 -          1     190618   40  160     19     20......0.0.....3......50......150.....10.... ref SDS U4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260419 -          1     190521   40  160     18     20......0.0.....3......50......200.....10.... ref SDS U0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260420 -          1     190416   40  160     18     20....100.0.....3......50......200.....10.... ref SDS T6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260421 -          1     190319   40  160     19     20......0.0.....3......50......150.....10.... ref SDS T4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260422 -          1     190215   40  160     19     20......0.0.....3......50......150.....10.... ref SDS T0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260423 -          1     190118   40  160     18     20......0.0.....3......50......150.....10.... ref SDS S4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260424 -          1     181218   40  160     18     20......0.0.....4......50......150.....10.... ref SDS S4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260425 -          1     181127   40  160     18     20......0.0.....3......25......250.....10.... ref SDS S3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260426 -          1     181030   40  160     18     20......0.0.....3......25......250.....10.... ref SDS S1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260427 -          1     181002   40  160     18     20......0.0.....3......25......250.....10.... ref SDS S0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260428 -          1     180904   40  160     16.5   19......0.0.....3......25......250.....10.... ref SDS R5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260429 -          1     180814   40  160     16     19......0.0.....3......25......250.....10.... ref SDS R3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260430 -          0.5   180713   40  160     16.5   18......0.0.....3......25......250.....10.... ref SDS R0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260431 -          2.5   180627   40  160     12     16.5....0.0.....3......25......250.....10.... ref SDS Q8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260432 -          2     180417   40  160     16.5   19......1.0.....3......25......250.....10.... ref SDS P8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260433 -          1.50  180227   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260434 -          1.25  180109   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260435 -          1     171128   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS O9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260436 -          2     171031   40  160     15.5   18......1.0.....4......25......250.....10.... ref SDS O5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260437 -          1.53  170905   80   80     15     18......1.0.....3......25......250.....10.... ref SDS O1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260438 -          1.53  170516   80   80     16.5   19......1.0.....5......25......250.....10.... ref SDS N6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260439 -          1.53  170404   80   80     16.5   18......1.5.....5......25......200.....10.... ref SDS N0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260440 -          1.53  170221   80   80     15     18......2.0.....5......25......200......5.... ref SDS M3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260441 -          0.80  170106   80   80     16.5   18......2.0.....5......25......200......5.... ref SDS L7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260442 -          0.23  161213   80   80     15     18......3.0.....5......25......200......5.... ref SDS L1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260443 -          0.20  161206   80   80     11     16.5....1.0.....5......25......200......5.... ref SDS K7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260444 -          0.27  161130   80   80     11     15......0.0.....5......25......200......5.... ref SDS K4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260445 -          0.23  161122   80   80      6     12......0.0.....5......25......200......5.... ref SDS K2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260446 -          1.40  161115   42   80     10     10......0.0.....5......25......200......5.... ref SDS J8 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260447 -          0.83  161004   26   80     11     15......5.0.....5......25......200......5.... ref SDS J2 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260448 -     *1   0.80  160909   80    0     10     15......5.0.....5......25......200......5.... ref SDS I8 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260449 -          2     160816   11   40      9.5   10......5.0.....4......50......150......5.... ref SDS I2 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260450 -          3     160617   10   40      9.5   15......5.0.....6......50......250......5.... ref SDS G9 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260451 -     *2   3     160315   15   40      9.5   15......3.0.....5......25......250......5.... ref SDS G7 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260452 -          8     151204   32   20     10     15......5.0.....5......25......200......5.... ref SDS F3 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260453 -     *3   6     150421   41          16.5   18......3.0.....4......50......250......5.... ref SDS D3 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260454 -          6     141107   37          15     18......4.0.....5......50......150......5.... ref SDS C4 E54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260455 -          6     140509   24          16.5   18..............5......50......200......5.... ref SDS B4 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260456 -     *4   7     131115   24          16.5   18......2.0.....4......50......200......5.... ref SDS A6 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260457 -          3     130416   38          18     18......2.0.....5......50......250......5.... ref SDS A0 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260458 -          4     130110   39          15     18......3.0.....4......50......100......5.... ref SDS 95 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260459 -     *5   6     120925   38          15     18......4.0.....5......50......200......5.... ref SDS 87 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260460 -     *6   4     120322   27          16.5   18..............4......50......150......5.... ref SDS 84 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260461 -     *7   3     111115   76          16.5   18..............4......50......200......5.... ref SDS 81 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260462 -          4     110819   80          15     16.5....2.5.....5......50......200......5.... ref SDS 80 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260463 -          2     110429   80          13     16.5....3.5.....5..............200......5.... ref SDS 75 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260464 -          2     110218   80          11     14......2.0.....4......50......150......5.... ref SDS 71 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260465 -          4     101210   40          11     14......................................5.... ref SDS 66 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260466 -          6     100827    4          11     15..............5......50......250......5.... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260467 -          3     100305    0          11     15..............5......50......250......5.... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260468 -          -     091216               Heller Myotomy Fundoplication................. ref SDS 36 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260470 -         ..
260471 -     ** Dates are from case study on exercise, diet, vitals and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260472 -        medication, shown on 160101, ref SDS G0 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260473 -        previously on 140101. ref SDS A9 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260474 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260475 -     *1 On 160911 paused Pantoprazole to reduce dehydration through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260476 -        frequent urination until after Half Dome, and resumed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260477 -        160920.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260478 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260479 -     *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS A9 E64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260480 -        Resumed Omeprazole 20 mg on 160323. ref SDS G0 RSXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260482 -         ..
260483 -        On 150924 hospitalized hematoma debridement; begin Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260484 -        20 mg per day. ref SDS A9 JT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260485 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260486 -     *3 On 150920 about 5 attacks convulsions, nausea not taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260487 -        Omeprazole - took 40 mg. ref SDS A9 656M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260488 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260489 -     *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260490 -        20 mg for next 5 months. ref SDS A6 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260492 -         ..
260493 -     *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260494 -        20 mg per day, shown in case study on 120101 0900, ref SDS 83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260495 -        AD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260496 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260497 -     *6 On 120907 Doctor Egan research found Omeprazole increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260498 -        blood pressure, sensed possible correlation patient sudden                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260499 -        rise in blood pressure, recommended reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260500 -        to 20 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260502 -     *7 On 11115 Doctor Lee prescribed continue PPM 80 mg; on 111201,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260503 -        patient reduced dose to 20 mg on record of rising blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260504 -        pressure despite increased hiking; research indicated PPI may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260505 -        elevate blood pressure, see case study 101010 0744, ref SDS 57 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260508 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260510 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260512 -  ..
260513 - Conscious Sedation Reduced Dose Applied for 11 Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260514 - 
260515 - Follow up ref SDS U4 714N, ref SDS U0 714N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260516 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260517 - Nursing Procedural Sedation & Analgesia Flow Sheet Record Page 1 shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260518 - versed 3 ML.  Since procedure only took 11 minutes, ref SDS U4 Q65I,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260519 - the doctor was able to minimize exposure to versed, which previously                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260520 - caused stroke symptoms with 6 ml, as occurred on 160617 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260521 - ref SDS G9 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260523 -  ..
260524 - No post procedure side effects as occurred previously on 161213 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260525 - ref SDS L1 R74J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260527 -  ..
260528 - Seem sleepy though even hours after the procedure using 3 ml versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260529 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260531 -  ..
260532 - Ulceration on Esophagus Above LESV Significantly Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260533 - 
260534 - Follow up ref SDS U4 RZ3G, ref SDS U0 RZ3G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260536 - Doctor Lee reported this morning that EGD procedure found that both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260537 - minor ulcerations on the side of esophagus above LESV are now                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260538 - completely resolved.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260540 -  ..
260541 - As a result, he omitted Triamcinalone again today, and maintained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260542 - medication regimen taking Pantoprozole everyday - see case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260543 - above. ref SDS U4 YR4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260545 -  ..
260546 - Doctor Lee did not have time to present pictures showing improved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260547 - condition with reduced ulceration of LESV, following EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260548 - procedure today, per above. ref SDS T0 GD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260550 -  ..
260551 - Pictures from procedure were later received on 190316...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260552 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260553 -              F:\05\00003\SM\CC\AGMJ\20190215-080000\MAC00029033884.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260555 -  ..
260556 - Decided to continue pentoprazole everyday before dinner for next 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260557 - weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260558 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260560 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260562 -  ..
260563 - Schedule Next Procedure and Post Procedure Review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260564 - 
260565 - Follow up ref SDS U4 XF6X, ref SDS U0 XF6X.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260566 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260567 - Next procedure is on 190813 0730, scheduled by Jessica in the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260568 - on 190416 0800. ref SDS T5 DS7O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260570 -  ..
260571 - Doctor Lee advised that if LESV condition is as good next month as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260572 - seen today, they we may skip procedure scheduled on 190917, and do                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260573 - the next EGD dilation on 191015.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260574 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260575 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260576 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260577 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260578 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260579 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260580 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 U4 Q05K, ref SDS U0 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\20190618-073000\WELCH.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270428 -  ..
270429 - Stored photographs for procedure on 190521 at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270430 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270431 -              F:\05\00003\SM\CC\AGMJ\20190618-073000\MAC00032602751.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270432 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270433 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270435 -         ..
270436 -    1.  LOCAL TITLE: EGD Procedure Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270437 -        STANDARD TITLE: GASTROENTEROLOGY DIAGNOSTIC STUDY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270438 -        DATE OF NOTE: JUN 18, 2019@18:46:26  ENTRY DATE: JUN 18, 2019@18:46:26                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270439 -        AUTHOR: CLINICAL,DEVICE PRO  EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270440 -        URGENCY: STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270441 -        *** EGD Procedure Report Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270442 -        ** DOCUMENT IN VISTA IMAGING **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270443 -        SEE FULL REPORT IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270444 -        SIGNATURE NOT REQUIRED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270445 -        SEE SIGNATURE IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270446 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270447 -        ** (PENTAX EGD)  AUTO-INSTRUMENT DIAGNOSIS **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270449 -         ..
270450 -    2.  Procedure: EGD  UPPER ENDOSCOPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270452 -         ..
270453 -    3.  PENTAX INSTRUMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270454 -        10535 Hospital Way Mather CA, 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270456 -         ..
270457 -    4.  EGD PROCEDURE REPORT     EXAM DATE: 06/18/2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270461 -        VISIT #:  3190618065623                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270463 -         ..
270464 -    5.  ATTENDING:     Randall Lee, MD STATUS:     outpatient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270465 -        ASSISTING MD:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270466 -        ASSISTANT:  Hazel Arenzana, RN and Edward Harris, Tech                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270468 -         ..
270469 -    6.  INDICATIONS: The patient is a 74 yr old male here for an EGD due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270470 -        PROCEDURE PERFORMED:   EGD diagnostic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270471 -        MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270472 -        TOPICAL ANESTHETIC:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270474 -         ..
270475 -    7.  CONSENT:  The risks, benefits, and alternatives to this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270476 -        procedure including but not limited to the risks of bleeding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270477 -        and bowel perforation were explained to the patient.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270478 -        patient understood and provided written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270480 -         ..
270481 -    8.  DESCRIPTION OF PROCEDURE:  In the Sacramento VA GI Endoscopy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270482 -        Unit,  Informed consent was verified, confirmed and timeout was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270483 -        performed.  The patient was placed in left lateral decubitus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270484 -        position.  Oxygen was administered.  Continuous oximetric and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270485 -        hemodynamic monitoring was initiated.  Intravenous sedation was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270486 -        administered in divided doses.  After a bite block was placed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270487 -        in the patient's mouth,  the GIF-HQ190-2858018 videoscope was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270488 -        introduced under direct vision through the mouth and advanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270489 -        to the   .  The stomach and esophagus were decompressed, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270490 -        the gastroscope removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270492 -         ..
270493 -    9.  ADVERSE EVENTS:     There were no complications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270494 -        IMPRESSIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270495 -        RECOMMENDATIONS:     EGD balloon dilation esophagus 30357 dictated:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270496 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270497 -        distal esophageal GERD stricture dilated 18-19-20mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270499 -         ..
270500 -        REPEAT EXAM:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270501 -        ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270502 -        Randall Lee, MD eSigned:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270503 -        Randall Lee, MD 6/18/2019 18:46:17                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270505 -        cc:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270508 -         ..
270509 -   10.  PATIENT NAME:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270512 -        Administrative Closure: 06/18/2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270513 -        by: CLINICAL,DEVICE PROXY SERVICE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270514 -        06/18/2019 ADDENDUM                 STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270518 -         ..
270519 -   11.  NAME OF PROCEDURES:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270520 -        1.  Esophagogastroduodenoscopy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270521 -        2.  Through the scope balloon dilation of esophageal stricture.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270523 -         ..
270524 -        ATTENDING PHYSICIAN:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270525 -        Randall E. Lee, MD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270527 -         ..
270528 -   12.  INDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270530 -        74-year-old man who had a laparoscopic myotomy and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270531 -        fundoplication at the San Francisco VA in 2009 for treatment of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270532 -        achalasia.  Subsequently he developed esophageal reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270533 -        complicated by a stricture that has required repeated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270534 -        endoscopic dilations.  His most recent EGD was May 21, 2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270535 -        showing 2 linear ulcerations in the distal esophagus believed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270536 -        to be due to prior triamcinolone injection.  The stricture had                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270537 -        a probable initial luminal diameter of between 18 to 19 mm and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270538 -        was dilated to 20 mm.  Since then, he has continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270539 -        pantoprazole daily 40 mg with the addition of famotidine 80 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270540 -        in the morning plus 80 mg in the evening plus Mylanta 40 mL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270541 -        plus calcium carbonate 1000 mg orally.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270543 -         ..
270544 -        He notes some occasional episodes of bloating, regurgitation,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270545 -        and pyrosis, particularly at bedtime for which he has used                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270546 -        sodium bicarbonate solution.  He believes this may be related                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270547 -        to late night eating or snacking.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270549 -         ..
270550 -        He continues to remain very physically active, and he is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270551 -        undergoing platelet injection therapy.  He has not noticed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270552 -        significant symptoms of dysphagia since his last dilation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270554 -         ..
270555 -        He is requesting additional supplies of Mylanta to combat his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270556 -        occasional pyrosis symptoms.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270558 -         ..
270559 -   13.  CONSENT:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270560 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270561 -        The risks, benefits, and alternatives to this procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270562 -        including but not limited to the risks of bleeding and bowel                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270563 -        perforation were explained the patient.  The patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270564 -        understood and provided written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270566 -         ..
270567 -   14.  INTRAVENOUS MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270568 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270569 -        1.  Diphenhydramine 50 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270570 -        2.  Fentanyl 150 mcg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270571 -        3.  Midazolam 3 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270573 -         ..
270574 -   15.  PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270575 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270576 -        At the Sacramento VA GI Endoscopy Unit, the patient was placed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270577 -        in left lateral decubitus position.  Oxygen at 2 liters per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270578 -        minute by nasal cannula was administered.  Continuous oximetric                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270579 -        and hemodynamic monitoring was initiated.  Intravenous sedation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270580 -        was administered in divided doses.  After a bite block was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270581 -        placed in the patient's mouth an Olympus GIF-HQ190 video                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270582 -        gastroscope was advanced under direct vision to the third                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270583 -        portion of the duodenum.  Retroflexed views of the incisura,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270584 -        fundus, and cardia were performed.  A TTS balloon was advanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270585 -        through the gastroscope and positioned across the lower                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270586 -        esophageal sphincter.  This was sequentially inflated from 18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270587 -        to 19 to 20 mm and held at 20 mm for 2 minutes.  The balloon                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270588 -        was deflated, removed, and the esophagus and stomach were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270589 -        decompressed and the gastroscope removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270591 -         ..
270592 -   16.  COMPLICATIONS:  None immediate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270594 -         ..
270595 -   17.  FINDINGS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270596 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270597 -        1.  Accumulation of saliva within the esophageal body that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270598 -            required irrigation and suctioning.  The proximal and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270599 -            mid-esophageal body were dilated and without noticeable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270600 -            peristaltic waves.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270602 -             ..
270603 -        2.  Tattoo site in the esophageal body at about 31 cm without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270604 -            evidence of mass effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270606 -             ..
270607 -        3.  Two linear ulcerations in the distal esophagus.  More                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270608 -            distal ulcer is shallow and nearly healed.  The more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270609 -            proximal ulceration is approximately 2 mm in diameter and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270610 -            has evidence of partial healing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270612 -  ..
270613 - Aligns with understandings during meeting with the doctor after the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270614 - procedure, shown above. ref SDS U4 RZ3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270616 -  ..
270617 - Findings continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270618 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270619 -        4.  Mild mucosal tear noted after balloon dilation from 19 to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270620 -            20 mm.  This is associated with mild self-limited oozing of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270621 -            blood but no evidence of perforation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270623 -             ..
270624 -        5.  GE junction located at 38 cm with the diaphragm located at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270625 -            40 cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270627 -             ..
270628 -        6.  Normal appearing gastric mucosa in the fundus and body with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270629 -            gastric fundus appearance consistent with prior history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270630 -            fundoplication with relaxation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270632 -             ..
270633 -        7.  Patchy gastric mucosal erythema in the antrum again noted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270634 -            without erosion, ulceration, or mass effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270636 -             ..
270637 -        8.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270639 -             ..
270640 -        9.  Normal duodenum to D3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270642 -         ..
270643 -   18.  IMPRESSION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270644 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270645 -        1.  Distal esophageal stricture secondary to acid reflux.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270646 -            lumen of the stricture appears to be relatively maintained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270647 -            since last month as there is only a small amount of trauma                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270648 -            after dilation from 19 to 20 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270650 -             ..
270651 -        2.  Prior esophageal ulcerations appear to be healing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270653 -  ..
270654 - Aligns with understandings during meeting with the doctor after the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270655 - procedure, shown above. ref SDS U4 RZ3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270657 -  ..
270658 - Findings continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270659 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270660 -        3.  Dilated esophageal body with absence of peristalsis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270661 -            consistent with known diagnosis of achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270663 -             ..
270664 -        4.  The patient's notation of more frequent pyrosis is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270665 -            consistent with maintenance of lower esophageal sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270666 -            lumen diameter combined with some dietary indiscretion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270667 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270669 -         ..
270670 -   19.  RECOMMENDATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270671 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270672 -        1.  Continue daily pantoprazole 40 mg once daily, although the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270673 -            patient believes that this is contributing to recurrence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270674 -            of his plantar dyshidrosis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270675 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270676 -        2.  Continue medical regimen of famotidine 40 mg twice daily                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270677 -            plus Mylanta 40 mL plus calcium carbonate 1000 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270679 -             ..
270680 -        3.  Repeat EGD and dilations currently scheduled approximately                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270681 -            4 to 6 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270683 -             ..
270684 -        4.  Continue use of liquid nutritional supplements as necessary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270685 -            to maintain weight given the patient's recurrent episodes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270686 -            of esophageal stenosis and achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270688 -         ..
270689 -   20.  TIME START: 0852 hours                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270690 -        TIME END: 0903 hours                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270692 -         ..
270693 -        D:  6/18/2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270694 -        T:  6/19/2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270695 -        Job number:  30357                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270696 -        DMC/AP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270697 -        $end:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270698 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270699 -   21.  /es/ Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270700 -        Staff Physician, Gastroenterology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270701 -        Signed: 06/25/2019 15:49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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270708 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270709 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2708 -