posted by Amber .
I. AMBULATORY CARE FACE SHEET
Admit Date: 7/8/20XX @ 20:22 Discharge Date/Time: 7/9/20XX @ 10:10
Sex: M Age: 47 Disposition: Home
Admitting Diagnosis: Possible esophageal foreign body.
Discharge Diagnosis: Esophageal foreign body.
Procedures: EGD with foreign body removal.
Date of Consultation: 7/8/20XX
This is a 47-year-old male who was in his usual state of health until early this evening when he developed an acute episode of odynophagia and a sensation of a foreign body in the proximal esophagus. This occurred after the patient had several bites of fish. The patient was evaluated with C-spine films and soft-tissue films, but no definite foreign body was seen. The soft tissue was noted to be normal. The patient, however, continued to have a sensation of a foreign body in the proximal esophagus and was complaining of upper esophageal pain. He has no past history of dysphagia, tobacco abuse, peptic ulcer disease, or reflux history. The patient has no past history of lye or corrosive substance ingestion. He denies any fever, chills, or shortness of breath.
Past Medical History:
Allergies: No known drug allergies.
Surgeries: Repair of a laceration to the forehead 10 months ago.
Medical History: History of hepatitis.
Family History: Noncontributory.
Review of Systems: No medical abnormalities.
Vital Signs: BP 130/80, P 92, T 98.5
This is a well-developed and well-nourished anxious black male in mild distress. Head and neck are normocephalic, atraumatic. Sclerae clear. The oropharynx is clear. The neck is supple with free range of motion and no thyromegaly. The trachea is midline and mobile. There is no crepitus noted. Lungs are clear bilaterally. Heart is regular rate and rhythm. Abdomen is soft and nontender with bowel sounds active in all four quadrants. There are no hepatosplenomegaly or masses noted. Rectal is deferred. Musculoskeletal with free range of motion. Neurologic with no focal deficits.
Foreign body in upper esophagus or possible laceration of this area. We will plan for upper endoscopy to rule out an acute obstruction and, if necessary, remove the foreign body.
II. II.OPERATIVE REPORT
Date of Procedure: 7/8/20XX
Procedure: Esophagogastroduodenoscopy with foreign body removal.
Preoperative Medication: Demerol 50 mg IV, Versed 3 mg IV, Cetacaine spray
1. Esophageal foreign body.
Postoperative Diagnosis: Status-post foreign body removal.
Clinical Note: This is a 47-year-old black male who experienced acute odynophagia after initially eating a meal consisting of fish. The patient felt a foreign-body-like sensation in his proximal esophagus and presented to the emergency room. He was evaluated with lateral, C-spine films, and soft-tissue films without any evidence of perforation. The patient is now referred for evaluation for his proximal esophagus.
Findings: After obtaining informed consent, the patient was endoscoped in the emergency room. He was premedicated with Demerol and Versed without any complications. Under direct visualization, an Olympus Q20 endoscope was introduced orally, and the esophagus was intubated without any difficulty. The hypopharynx was carefully reviewed, and no abnormalities were noted. There were no foreign bodies or lacerations to the hypopharynx. The proximal esophagus was normal. No active bleeding was noted. The endoscope was farther advanced into the esophagus, where careful review of the mucosa revealed no foreign bodies and no obstructions. The distal esophagus did, however, show a very small fish bone, which was removed without any complications. The endoscope was advanced into the stomach, where partially digested food was noted. The endoscope was then removed. The patient tolerated the procedure well, and his post-procedure vital signs are stable.
1. Clear liquids for 24 hours.
2. Follow-up with me in the office in the morning.
Soft-tissue neck. There is a curvilinear density in the region of the base of the tongue that could conceivably represent a small bone. The airway is intact throughout. No other abnormalities are visible.
Admit to Endoscopy Department.
Obtain consent for procedure, signed and witnessed.
Start IV of 55 cc D5W or NS TO KVO or heparin lock.
Preoperative Medications: Versed 3 mg IVP, Demerol 50 mg IVP, apply pulse oximeter.