Esophageal reflux Other pneumothorax Other specified retention of urine
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: CARDIOTHORACIC
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Gastroesophageal reflux disease
 
Major Surgical or Invasive Procedure:
Laparoscopic ___ fundoplication

 
History of Present Illness:
The patient is a ___
gentleman whom I have been asked to see by Dr. ___
evaluation of gastroesophageal reflux disease.  The patient has 
a
history of irritable bowel syndrome with symptoms of abdominal
pain and diarrhea, although this has largely improved over the
past several years.  

His current symptoms include regurgitation of food, primarily
with coughing as well as occasional substernal chest pain.  His
primary complaint is dysphagia as well as odynophagia on eating
solid food.  The patient has seen an ENT physician, ___ 
___
also underwent a pH testing off of PPIs. This test performed in
___ shows ___ score of 25.9.

 
Past Medical History:
The patient has no significant past
medical history other than irritable bowel syndrome.

 
Physical Exam:
Gen: NAD, A&Ox3
Cardiac: RRR, no m/r/g
Pulm: CTAB
Abd: Soft, NTND
Extremeties: warm and well perfused
Incisions: covered with dermabond no evidence of infection, no 
bleeding or drainage
 
Pertinent Results:
Esophageal study ___
While standing, the patient was given a small amount of thin 
barium contrast to ingest.  Barium passed freely through the 
gastroesophageal junction and into the stomach.  There was only 
a small amount of residual contrast in the distal esophagus 
which cleared with tertiary contractions.  The patient was next 
laid horizontally and was given more contrast to ingest while in 
the right anterior oblique position.  No reflux was seen.  The 
patient was rolled into a number differentpositions to visualize 
the fundoplication and there is no evidence of loosening. 
  
IMPRESSION: 
  
Normal postoperative appearance of ___ fundoplication. 

 
Brief Hospital Course:
Mr. ___ was admitted on ___ to undergo a laparoscopic ___ 
fundoplication for his GERD.  The procedure was uncomplicated 
and he tolerated it well.  He was extubated and stable in the 
OR.  His stat CXR in the PACU revealved a small R apical 
pneumothorax however he was asymptomatic and repeat CXR 4 hours 
later revealed reinflation of the lung.  He never dropped his 
sat's or had difficulty breathing.  Post-operatively he has had 
some acute urinary retention for which he has a urinary foley 
catheter replaced.  Barium swallow on POD #1 showed no 
extravasation and his diet was advanced without problem.  He 
discharged to home on ___.
 
Medications on Admission:
Dexilant 60mg daily
albuterol ___ puff ___ prn
lorazepam 0.5mg QID:prn
oxybutynin ER 5mg QID
valacyclovir 500mg daily
Vitamin B12 daily
Loratidine 10mg daily
Lysine 1000mg 3 times per week

 
Discharge Medications:
1. Ondansetron 4 mg IV ONCE:PRN for nausea 
2. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Gastroesophageal reflux disease

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Difficult or painful swallowing
-Nausea, vomiting (take antinausea medication) 
-Increased shortness of breath

Pain
-Acetaminophen as needed for pain along with your narcotic
-Take stool softners with narcotics
-No driving while taking narcotics

Activity
-Shower daily. Wash incision with mild soap and water, rinse, 
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision
-Walk ___ times a day for ___ minutes increase to a Goal of 30 
minutes daily

Diet:
Full liquid diet for ___ days. Increase to soft solids as 
tolerates

Eat small frequent meals. Sit in chair for all meals. Remain 
sitting up for ___ minutes after all meals

NO CARBONATED DRINKS

 
Followup Instructions:
___

{'regurgitation of food': ['Esophageal reflux'], 'coughing': ['Esophageal reflux'], 'substernal chest pain': ['Esophageal reflux'], 'dysphagia': ['Esophageal reflux'], 'odynophagia': ['Esophageal reflux'], 'abdominal pain': ['Other specified retention of urine'], 'diarrhea': ['Other specified retention of urine'], 'R apical pneumothorax': ['Other pneumothorax'], 'acute urinary retention': ['Other specified retention of urine']}