DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING DIAGNOSIS: Dysphagia.
DISCHARGE DIAGNOSIS: Dysphagia secondary to esophageal stricture. The patient is status post EGD and balloon dilatation of the esophageal stricture.
SUMMARY AND HOSPITAL COURSE: The patient is an (XX)-year-old lady with past medical history of dysphagia for many years and also history of hypertension, coronary artery disease, and also status post CABG surgery for three-vessel disease.
The patient presented to the hospital with complaint of progressively worsening dysphagia. The patient was admitted to the hospital for inpatient treatment of dysphagia and for GI consultation on EGD. The patient was admitted to the hospital and discharged to home on the same day. The patient was evaluated by the gastroenterology service and underwent EGD.
EGD showed esophageal stricture, possibly secondary to underlying gastroesophageal reflux disease. The patient had a balloon dilatation of the esophageal stricture and also EGD confirmed that the patient has erosive gastritis. At discharge, we changed the patient’s aspirin to Plavix, and we also put the patient on Aciphex 20 mg once a day. Otherwise, we continued all of her home medications at discharge.
PAST MEDICAL HISTORY: Otherwise negative other than coronary artery disease and hypertension. The patient does not have any history of diabetes or high cholesterol. She does not have any history of lung problem, asthma, or COPD. She does not have any history of heart failure, arrhythmia, or AFib. She does not have any history of any stroke, seizure problems, or thyroid problem. She does not have any history of kidney problem or liver problem.
PAST SURGICAL HISTORY: Status post CABG for three-vessel disease.
ALLERGIES: The patient is allergic to penicillin, tetanus, and sulfa medications.
HABITS: The patient denies any history of smoking, alcohol abuse, or drug abuse.
FAMILY MEDICAL HISTORY: Not significant.
HOME MEDICATIONS: The patient had been taking blood pressure medication; the patient does not remember the name of the medication. She also had been taking aspirin 81 mg once a day.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.2 degrees, respiratory rate 18, blood pressure 168/70, heart rate 72, and saturation 100% on room air. HEAD AND NECK: There is no JVD. There is no lymphadenopathy. Neck is supple. Thyroid is nonpalpable. HEART: S1 and S2 normal. S3 and S4 negative. Pulse rhythmic, palpable in four extremities. There is no carotid bruit. There is no cardiac murmur. LUNGS: Breath sounds are equal bilaterally. There is no wheezing. There are no rhonchi. There are no crackles. ABDOMEN: Soft, no mass, no tenderness, and no rigidity. EXTREMITIES: There is no peripheral edema. There is no calf tenderness. NEUROLOGIC: There are no focal neurologic deficits. Cranial nerves are intact.
LABORATORY DATA: White count is 4800, hemoglobin is 10, hematocrit is 30, and platelets 126,000. Sodium 152, potassium 4.2, chloride 108, bicarbonate 24, BUN is 40, creatinine is 1.4, and glucose is 96. Gastric biopsy result is pending. Chest x-ray is unremarkable, except for findings consistent with COPD.
The patient denied any complaints other than dysphagia. She denied any chest pain. She denied any shortness of breath. She denies any cough or sputum production. She denies any abdominal pain. She denies any change in color of stool. She denies any diarrhea or constipation. She denies any urinary problem.
IMPRESSION AND PLAN: Our impression is that the patient has dysphagia secondary to esophageal stricture. The patient had esophageal dilatation, successful, during EGD and discharged to home with Aciphex and also Plavix, and we stopped her aspirin at discharge. We recommended the patient to follow up with her primary care physician within a week. We also recommended her to come to the hospital or call her primary care physician if she develops worsening of the dysphagia, chest pain, palpitations, or shortness of breath.
We will also recommend the patient’s primary care physician to check patient sodium level and BUN and creatinine at the next visit. The patient’s elevated sodium, BUN, and creatinine are secondary to dehydration. The patient had esophageal dilatation. We expect the patient to start eating and drinking better. We expect her sodium, BUN, and creatinine to improve as the patient’s oral intake will improve.
