DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: History of gastroesophageal reflux disease, dysphagia, and vomiting.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who has a history of gastroesophageal reflux disease, of many years’ duration, chronic dysphagia with a history of esophageal stricture and possible esophageal pseudodiverticula, coronary artery disease, and status post CABG. The patient was admitted for persisting vomiting at home yesterday. As per the patient’s wife, he has had an EGD and esophageal dilation on him about three months ago by his primary gastroenterologist. He was told that he has a stricture in the esophagus with possible esophageal pseudodiverticula, and no further endoscopy was recommended by him three months ago.
The patient has had chronic dysphagia for the last five to six years, and he has had repeated esophageal dilations on him. Following the last dilation, three months ago, there was no further improvement in his dysphagia and is able to swallow soft food and liquids at this time. He has no history of choking. He does feel the food is slowly moving down the chest. He does not have any chest pain or abdominal pain. No history of GI bleed. He had persisting episodes of vomiting yesterday because of which he was brought to the ED. Following admission, he received intravenous hydration with Protonix and is able to swallow a clear liquid diet today. There is no recent history of weight loss. His bowel movements, otherwise, are regular. There is no history of blood in the stools.
PAST MEDICAL HISTORY: Significant for CABG and pacemaker placement.
MEDICATIONS: The patient is on Protonix, atenolol, and Ativan.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: The patient is married and he has one child.
SOCIAL HISTORY: The patient does not smoke, does not drink alcohol, and does not do any injection drugs.
REVIEW OF SYSTEMS: Otherwise, negative for other systems.
PHYSICAL EXAMINATION: The patient is a (XX)-year-old male who is alert and oriented x3. He is comfortable at rest. The patient’s vital signs include temperature of 98.2, heart rate of 60, blood pressure of 138/64, and respirations of 21. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. ENT examination is unremarkable. No JVD or lymphadenopathy appreciated. No thyromegaly. Neck is supple. First and second heart sound normally heard. No third sound, no fourth sound, and no murmur. Auscultation of the lungs showed bilateral vesicular breath sound. On examination of the abdomen, there is a soft and scaphoid abdomen. There is no tenderness in the abdomen. No hepatosplenomegaly appreciated. No ascites. Normal peristaltic sounds are heard. On examination of the extremities, no edema and no rash noted. The patient has no focal neurological deficits.
LABORATORY DATA: The patient had his labs three days ago, which showed a white blood count of 7.5, hemoglobin 10.6, and platelet count 192 with MCV 92. Electrolyte panel showed sodium 141, potassium 4.6, bicarbonate 24, chloride 108, BUN 26, creatinine 1.2, and glucose of 115.
ASSESSMENT AND PLAN:
1. History of gastroesophageal reflux disease with chronic dysphagia with a possible esophageal stricture and esophageal pseudodiverticula. As per the patient’s wife, the patient has had an esophagogastroduodenoscopy with esophageal dilation on him three months ago, which did not help him with his dysphagia. At this point in time, he is able to swallow clear liquids and was able to swallow a full liquid diet at home. The patient did not have any further emesis after being admitted to the hospital. The patient and his family, at this time, were not interested in proceeding with any endoscopic evaluation on him. They want to take him to follow with his primary gastroenterologist. At this time, he is tolerating a clear liquid diet, which is to going to be advanced to full liquid diet and will be discontinued home in the a.m. tomorrow, if he tolerates the full liquid diet. Protonix is going to be changed to Prevacid liquid 30 mg p.o. daily at this time. The patient and his wife were informed about a possible feeding tube placement, in case he continues to have dysphagia, and the esophageal dilation cannot be accomplished because of the pseudodiverticula on him.
2. Coronary artery disease, status post coronary artery bypass graft and pacemaker placement. Continue home medication.
