Dysphagia Consult Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION:
1. Dysphagia.
2. History of esophageal stricture.
3. Severe anemia, hemoglobin of 4.6, causing weakness.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old pleasant African-American man with a history of esophageal stricture, foreign body impaction x2, and disimpaction with endoscopies with history of status post Billroth surgery, glucose intolerance, complaining of severe weakness, who presented to the emergency department complaining of epigastric pain and also dysphagia to solids at times. On further workup, he was noted to have hemoglobin as mentioned above, 4.6, and so far, the patient was on 4 units of PRBCs and repeat CBC is pending.
The patient feels very well. No chest pain now. No abdominal pain, no fever or no chills. No melena or change in bowel habits. The patient has hematuria after having some bladder problems for his bladder carcinoma.
PAST MEDICAL HISTORY: As mentioned above.
HOME MEDICATIONS: Insulin.
ALLERGIES: NKDA.
FAMILY HISTORY: No history of colorectal cancer.
REVIEW OF SYSTEMS: HEENT: No headache. Cardiac: No chest pain. Respiratory: No shortness of breath. Gastrointestinal: As in HPI. Genitourinary: Positive for hematuria.
PHYSICAL EXAMINATION:
VITAL SIGNS: Awake, alert, and oriented x3. Pulse of 54, blood pressure 124/62, and weight not documented.
HEENT: Conjunctivae clear.
NECK: No JVD.
CHEST: Clear.
HEART: Regular.
ABDOMEN: Soft and nontender.
EXTREMITIES: No cyanosis or clubbing.
RECTAL: No stool noted.
LABORATORY DATA: Admission labs revealed WBC of 4.2, hemoglobin 4.6, hematocrit 17.8, and platelets 194,000. INR 1.12. Sodium 138, potassium 3.9, chloride 108, BUN 15, creatinine 1.0, total bilirubin 1.6, alkaline phosphatase 70, ALT 13, AST 26, CK-MB 7.6, and troponin 0.01 x2.
ASSESSMENT AND PLAN:
1. This is a (XX)-year-old who presented to the emergency department with history of esophageal stricture, status post food impaction and now recurrent dysphagia, most likely to benign esophageal stricture.
2. Severe anemia, questionable from genitourinary, from his bladder losses.
PLAN:
1. Given his dysphagia and severe anemia, we will transfuse to keep his hematocrit greater than 30 and guaiac stools x3.
2. Urology consultation.
3. Esophagogastroduodenoscopy with plus or minus dilatation for the above symptomatology.
4. Clearly discussed the risks, benefits, and alternatives for the above and agrees for above.
