DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: Today, we had the pleasure of seeing this patient in the gastroenterology clinic. He is a (XX)-year-old male who presents here for further evaluation. He was initially seen two months ago for a food impaction and was found to have an esophageal stricture, which was again complicated in the mediastinum anterior to the trachea. The patient was managed conservatively and was discharged. Now, he presents here with solid food dysphagia and also is receiving treatment for his lung cancer. The patient denies any pain on swallowing, fever or chills, change in medication.
PAST MEDICAL HISTORY: Thrombocytopenia and diabetes type 1, chronic kidney disease, non-small cell lung cancer N2M0 confirmed by biopsy of the mediastinal nodes three months ago.
PAST SURGICAL HISTORY: Benign esophageal stricture status post dilation x2, endoscopic right carotid endarterectomy, epidermal inclusion cyst, flexible bronchoscopy with medistinal washings and a PET positive lymph node in the mediastinum.
SOCIAL HISTORY: The patient has a 60-pack-year history of smoking and was drinking about 2-3 beers per day but has cut back, former smoker, episodic alcohol use, and no illicit drugs.
FAMILY HISTORY: Father had stomach cancer.
REVIEW OF SYSTEMS: All other review of systems otherwise negative.
PHYSICAL EXAMINATION:
GENERAL: Reveals a healthy-appearing, pleasant male in no acute distress.
VITAL SIGNS: Reviewed. BMI is 22.
HEART: S1, S2 heard.
LUNGS: Bilateral air entry good, clear and no crepitus.
ABDOMEN: Soft, nontender, bowel sounds positive.
EXTREMITIES: No edema, positive pulses.
PSYCHIATRY: Appropriate mood and affect.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old male with esophageal stricture status post food impaction and mild amount of pneumomediastinum about two months ago. At this point, we would schedule the patient for an upper endoscopy and possible dilation. The etiology for his dysphagia could be multifactorial, could be related to infectious etiologies suggestive of Candida or other etiologies such as radiation or malignancy are possible and can be excluded with an upper endoscopy and dilation plus or minus biopsies if needed. It has to be noted that the recent CAT scan did not show any esophageal mass. The patient will be scheduled for an upper endoscopy under general anesthesia for further treatment.
