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.
CONSULTATION
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.
Medications: None.
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.
Physical Examination:
Vital Signs: BP 130/80, P 92, T 98.5
General:
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.
Impression:
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
Preoperative Diagnosis:
1. Esophageal foreign body.
2. Odynophagia.
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.
Recommendations:
1. Clear liquids for 24 hours.
2. Follow-up with me in the office in the morning.
RADIOLOGY REPORTS
Date: 7/8/20XX
Procedure Performed:
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.
ENDOSCOPY ORDERS
Date: 7/8/20XX
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.
Section I:
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.
CONSULTATION
Date of Consultation: 7/8/20XX
- Patient's usual state of health until early evening when he developed acute episode of odynophagia and sensation of foreign body in the proximal esophagus after eating fish
- Evaluated with C-spine and soft-tissue films, no definite foreign body seen
- Patient continued to have sensation of foreign body and complained of upper esophageal pain
- No past history of dysphagia, tobacco abuse, peptic ulcer disease, reflux history
- No past history of lye or corrosive substance ingestion
- Denies fever, chills, or shortness of breath
Past Medical History:
- Allergies: No known drug allergies
- Medications: None
- 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
Physical Examination:
- Vital Signs: BP 130/80, P 92, T 98.5
- General: Well-developed and well-nourished anxious black male in mild distress
- Head and neck: Normocephalic, atraumatic. Sclerae clear. Oropharynx clear. Neck supple with free range of motion, no thyromegaly. Trachea midline and mobile. No crepitus.
- Lungs: Clear bilaterally
- Heart: Regular rate and rhythm
- Abdomen: Soft and nontender, bowel sounds active in all four quadrants. No hepatosplenomegaly or masses.
- Musculoskeletal: Free range of motion
- Neurologic: No focal deficits
Impression:
- Foreign body in upper esophagus or possible laceration in this area
- Plan for upper endoscopy to rule out acute obstruction and, if necessary, remove the foreign body
In this medical document, Section I provides information about the ambulatory care face sheet. It includes details about the patient's admission and discharge dates and times, as well as their sex, age, and final disposition (being sent home). It also mentions the admitting diagnosis, which is a possible esophageal foreign body, and the discharge diagnosis, which confirms the presence of an esophageal foreign body. The procedure performed on the patient is an esophagogastroduodenoscopy (EGD) with foreign body removal.
Section II:
Section II contains the operative report for the procedure performed on the patient. It provides details about the pre-operative medication given to the patient, including Demerol and Versed, as well as Cetacaine spray. The preoperative diagnosis includes an esophageal foreign body and odynophagia. The postoperative diagnosis is mentioned as the status-post foreign body removal. The clinical note explains that the patient experienced odynophagia after eating fish and was evaluated in the emergency room, where lateral, C-spine, and soft-tissue films were taken to rule out any perforation. The findings during the procedure include the absence of any abnormalities in the hypopharynx and the presence of a small fish bone in the distal esophagus, which was successfully removed. The recommendations after the procedure include a clear liquid diet for 24 hours and a follow-up office visit.
Radiology Reports:
The radiology reports indicate that a soft-tissue neck scan was performed and showed a curvilinear density in the region of the base of the tongue, potentially indicating a small bone. The airway appeared to be intact, and no other abnormalities were visible.
Endoscopy Orders:
The endoscopy orders include instructions to admit the patient to the endoscopy department, obtain consent for the procedure, start an intravenous (IV) line with either 55 cc of D5W or NS to keep the vein open (KVO), or use a heparin lock. The preoperative medications listed are Versed and Demerol, and a pulse oximeter is to be applied.