Dysphagia unspecified Other specified symptoms and signs involving the circulatory and respiratory systems Angiodysplasia of stomach and duodenum without bleeding Gastro-esophageal reflux disease without esophagitis Diaphragmatic hernia without obstruction or gangrene Anxiety disorder unspecified Nonrheumatic mitral (valve) prolapse Age-related osteoporosis without current pathological fracture Personal history of nicotine dependence
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
omeprazole
 
Attending: ___.
 
Chief Complaint:
dysphagia 
 
Major Surgical or Invasive Procedure:
Upper endoscopy ___

 
History of Present Illness:
 ___ w/ anxiety and several years of dysphagia who p/w worsened 
foreign body sensation. 

She describes feeling as though food gets stuck in her neck when 
she eats. She put herself on a pureed diet to address this over 
the last 10 days. When she has food stuck in the throat, she 
almost feels as though she cannot breath, but she denies trouble 
breathing at any other time. She does not have any history of 
food allergies or skin rashes. 
 
In the ED, initial vitals:  97.6  81  148/83  16  100% RA 
Imaging showed: CXR showed a prominent esophagus
Consults: GI was consulted.

Pt underwent EGD which showed a normal appearing esophagus. 
Biopsies were taken.

Currently, she endorses anxiety about eating. She would like to 
try eating here prior to leaving the hospital. 

 
Past Medical History:
- GERD  
 - Hypercholesterolemia  
 - Kidney stones  
 - Mitral valve prolapse  
 - Uterine fibroids  
 - Osteoporosis  
 - Migraine headaches 
 
Social History:
___
Family History:
+ HTN - father  
+ Dementia - father  
 
 
Physical Exam:
=================
ADMISSION/DISCHARGE EXAM
=================
VS:  97.9  PO 109 / 71 70 16 97 ra 
GEN: Thin anxious woman, lying in bed, no acute distress  
HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI  
NECK: Supple without LAD, no JVD  
PULM: CTABL no w/c/r
COR: RRR (+)S1/S2 no m/r/g  
ABD: Soft, non-tender, non-distended, +BS, no HSM  
EXTREM: Warm, well-perfused, no ___ edema  
NEURO: CN II-XII grossly intact, motor function grossly normal, 
sensation grossly intact  
 
Pertinent Results:
=============
ADMISSION LABS
=============

___ 08:27AM BLOOD WBC-5.0 RBC-4.82 Hgb-14.9 Hct-44.4 MCV-92 
MCH-30.9 MCHC-33.6 RDW-12.1 RDWSD-41.3 Plt ___
___ 08:27AM BLOOD ___ PTT-28.6 ___
___ 08:27AM BLOOD Glucose-85 UreaN-8 Creat-0.9 Na-142 K-3.6 
Cl-104 HCO3-22 AnGap-20
___ 08:27AM BLOOD ALT-11 AST-16 LD(LDH)-154 AlkPhos-63 
TotBili-1.0
___ 08:27AM BLOOD Albumin-4.8
=============
IMAGING
=============

CXR ___: 
IMPRESSION:  
  
Prominent esophagus on lateral view, without air-fluid level. 
Given the patient's history and radiographic appearance, barium 
swallow is indicated either now or electively. 
  
NECK X-ray ___:
IMPRESSION:  
  
Within the limitation of plain radiography, no evidence of 
prevertebral soft tissue swelling or soft tissue mass in the 
neck. 
 

EGD: ___
 Impression: Hiatal hernia
Angioectasia in the stomach
Angioectasia in the duodenum
 (biopsy, biopsy)
Otherwise normal EGD to third part of the duodenum 

Recommendations: - no obvious anatomic cause for the patient's 
symptoms
- follow-up biopsy results to rule out eosinophilic esophagitis
- follow-up with Dr. ___ if biopsies show eosinophilic 
esophagitis 

 
Brief Hospital Course:
Ms. ___ is a ___ with history of GERD who presents with 
subacute worsening of dysphagia and foreign body sensation. This 
had worsened to the point where she placed herself on a pureed 
diet for the last 10 days. She underwent CXR which showed a 
prominent esophagus but was otherwise normal. She was evaluated 
by Gastroenterology and underwent an upper endoscopy on ___. 
This showed a normal appearing esophagus. Biopsies were taken. 

TRANSITIONAL ISSUES:
-f/u biopsies from EGD
-if results show eosinophilic esophagitis, follow-up with Dr. ___. 
___ for management
-pt should undergo barium swallow as an outpatient for further 
workup of her dysphagia
-f/u with ENT as planned
#Code: Full (presumed) 
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID 

 
Discharge Medications:
1.  Omeprazole 20 mg PO BID  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-dysphagia and foreign body sensation

SECONDARY DIAGNOSIS:
-GERD 

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

 
Discharge Instructions:
Dear Ms. ___,

You were hospitalized at ___.

You came in due to difficulty swallowing. You had an endoscopy 
to look for any abnormalities in the esophagus. Thankfully, this 
was normal. They took biopsies, and you will be called with the 
results. You should have a test called a barium swallow as an 
outpatient.

We wish you all the best!
-Your ___ Team 
 
Followup Instructions:
___

{'dysphagia': ['Dysphagia', 'Gastro-esophageal reflux disease without esophagitis'], 'foreign body sensation': ['Dysphagia', 'Gastro-esophageal reflux disease without esophagitis'], 'anxiety': ['Anxiety disorder', 'unspecified']}