DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Large hiatal hernia.
2. Barrett esophagus.
PROCEDURE: Upper endoscopy.
COMPLICATIONS: None.
HISTORY: This is a (XX)-year-old Hispanic male with a history of irritable bowel syndrome, Barrett esophagus, and hiatal hernia who was admitted with severe abdominal pain. The patient did not feel well for two weeks prior to admission. He complained of nausea, distention, bloating, vomiting, and abdominal discomfort. The patient’s appetite was poor and he lost weight. He denied melena, hematochezia, hematemesis, jaundice, fever, chills, dysphagia, and odynophagia.
PAST MEDICAL HISTORY: Large hiatal hernia, delayed gastric emptying, gastroesophageal reflux disease, and Barrett esophagus.
PAST SURGICAL HISTORY: Diaphragmatic hernia repair, gastrojejunostomy, and shoulder surgery.
MEDICATIONS: Reglan 10 mg q.i.d., Nexium 40 mg b.i.d., and Neurontin t.i.d.
ALLERGIES: None.
SOCIAL HISTORY: Tobacco, two packs of cigarettes per day, ethanol rare.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION: General: Revealed a pleasant Hispanic male in no acute distress. Vital Signs: Blood pressure is 140/76, respirations 20, pulse 68, and temperature normal. HEENT: Exam revealed anicteric sclerae. Lungs: Exam revealed clear lungs. Heart: Exam revealed regular rate and rhythm. Normal S1 and S2. Abdomen: Examination of the abdomen revealed normoactive bowel sounds, soft, and positive right upper quadrant tenderness. Extremities: Without edema.
LABORATORY STUDIES: CBC, white blood cell count, hemoglobin, and platelet count were normal; although, he did have six bands in the differential. SMA-7 was normal.
HOSPITAL COURSE: Because of the severity of abdominal pain, weight loss, nausea, and vomiting, the patient was admitted to the general medical floor. He was given intravenous fluids, Dilaudid, and Prevacid. The patient underwent ultrasound of the abdomen, which was unremarkable. He was seen in consultation by Dr. John Doe. The patient underwent CT scan of the abdomen and pelvis, which revealed a large hiatal hernia. An upper endoscopy was completed, which again revealed a large hiatal hernia and Barrett esophagus. The patient also underwent an upper GI series, which revealed a moderately large sliding hiatal hernia with moderate gastroesophageal reflux and what appears to be the remnant of a fundoplication defect. There was also side-to-side gastrojejunostomy present within the stomach. The patient improved during the hospitalization. He will be following up with Dr. John Doe and will likely need surgery to correct the hiatal hernia.
DISCHARGE INSTRUCTIONS: Discharge medications were Reglan 10 mg a.c. and q.h.s., Nexium 40 mg b.i.d., and Neurontin 300 mg t.i.d. The patient will be following with Dr. John Doe in one week. He has instructions to call if he develops recurrent bouts of abdominal pain. He has instructions to resume his previously prescribed antireflux diet. The patient had instructions not to drive on the day of discharge. He may resume driving the following day.
