DIALOGUE

[doctor] okay raymond it looks like you've been having some difficulty swallowing over for a period of time could you tell me like what's going on
[patient] well i've been better for the last several weeks i've been noticing that it's been hard for me to swallow certain foods and i also have pain when i swallow down in my chest
[doctor] okay and when does it does it happen every time you eat
[patient] it hurts not every time it hurts when i when i swallow most foods but it's really just the bigger pieces of food that seem like they're getting stuck
[doctor] okay and what do you mean by bigger pieces of food like what's your diet like
[patient] well things have been stressed over the last couple of months so lacks a moving from the west coast of east coast so i've been drinking more eating things like pizza burgers i know it's not good but you know it's been pretty busy
[doctor] wow that sounds kinda stressful like what are you moving for
[patient] well i'm stressed because what i'm moving because you know i i do n't like the west goes so i i decided to move but you know it's just stressful
[doctor] uh uh
[patient] because i do n't know how my dog is gon na handle the travel but i do n't wan na put them into the carbo portion of the plane we fly out of her really bad stories of dogs got in the wreck
[doctor] okay so are you thinking of driving
[patient] i i think so i think i'm i think i'm gon na end up driving but that's still a a long trip
[doctor] yeah absolutely i can see how that would that would increase your stress but like with that have you lost any weight because of your symptoms
[patient] no i wish unfortunately i've gained some weight
[doctor] okay and do you have any other symptoms like abdominal pain nausea vomiting diarrhea
[patient] sometime my belly hurts up here
[doctor] okay alright so epigastric pain alright any blood in your stool or dark dark tarry stool
[patient] not that i noticed
[doctor] okay alright so i'm gon na go ahead and do my physical exam i'll be calling up my findings as i run through it if you have any questions please let me know alright so with your vital signs your blood pressure looks pretty decent we have it like one thirty three over seventy so that's fine your heart rate looks good you do n't have a fever i do notice that in your chart it looks like you have gained you know about like ten pounds over the last month so i i do understand when you say that you've experienced some weight gain your you're satting pretty well your o2 sat is at a hundred percent so and then your breathing rate is pretty normal at nineteen so i'm gon na go ahead and do my mouth exam there are no obvious ulcers or evidence of thrush present tonsils are midline your neck i do n't appreciate any adenopathy no thyroid thyromegaly on your abdomen it is nondistended active bowel sounds so when i press here on that top part of your stomach does it hurt
[patient] no i did that hurts
[doctor] okay pain to palpation of epigastric area how about now
[patient] no
[doctor] okay negative murphy's sign no peritoneal signs no rebound your on examination of the lungs they sound clear to auscultation bilaterally i do n't see any rash no lesion no bruising your eyes seem equal and reactive to light so all of these things sound pretty decent so let's talk about like the results that i got for your i reviewed the results of your barium swallow and it showed that you have two areas of mild narrowing in the mid and lower portions of your esophagus that can be found in patients experiencing something called esophagitis so for your primary primary problem you have acute esophagitis i wan na go ahead and prescribe protonix it's forty milligrams you're gon na take that once a day you should take it the first thing in the morning i also wan na prescribe to you something called carafate you take one gram four times a day for one month that's just gon na help kind of coat your the in the lining of your esophagus and like your stomach so that you're again like not producing a whole lot of acid like your your pretty much your the acid in your stomach is getting where it does n't need to be and it's a bit too strong so we're gon na give your body time to do a reset i wan na schedule you for an upper endoscopy just to be sure we are n't missing anything else i encourage you to change your diet and decrease alcohol and caffeine i know that's gon na be pretty hard with the move but you know once especially once you're settled in it's gon na be very important for us to to like focus on like getting well and eating healthy so that you know like you can you can move about your day as best as you can and and enjoy your move i want you to consider like eating slowly and chewing your food more thoroughly so that you do n't have to deal with those big pieces i also want you to avoid citrus foods fruits and spicy foods until your symptoms have improved i wan na see you again next week for that endoscopy i know there was a lot of information do you have any questions
[patient] no i think that's all good
[doctor] okay alright thank you so much for coming in

CLINICAL NOTE

CHIEF COMPLAINT

Difficulty swallowing.

HISTORY OF PRESENT ILLNESS

Raymond Taylor is a pleasant 67-year-old male who presents to the clinic today for difficulty swallowing. The patient notes that the pain has been occurring for the last several weeks. The pain radiates to his chest when he swallows. He notes that he does not have pain every time he eats but mostly when he has big pieces of food as they seem to get stuck. Mr. Taylor notes that it has been stressful for him the past couple of months as they moved from the West Coast to the East Coast, so he has been drinking more, and having pizza, and burgers more. He denies any weight loss, but endorses weight gain. The patient states that he has epigastric pain, but denies dark, tarry stools.

REVIEW OF SYSTEMS

Constitutional: Reports weight gain.
HENT: Reports dysphagia.
Gastrointestinal: Reports epigastric pain. Denies dark, tarry stools.
Neurological: Positive stress.

VITALS

BP: 133/70.
Heart rate looks good.
Temperature is within normal limits.
SpO2: 100%.
Respiratory rate: 19.

PHYSICAL EXAM

EYES: Equal and reactive to light.
NECK: No adenopathy, thyromegaly.
RESPIRATORY: Normal respiratory effort no respiratory distress
GI/GU: Non-distended Active bowel sounds. Pain to palpation of epigastric area. Negative McMurphy's Sign. No peritoneal signs. No rebound.
SKIN: No rash, no lesion, no bruising.
MSK: Examination of the mouth reveals no obvious ulcers or evidence of thrush present. Tonsils are midline of the neck.

RESULTS

The barium swallow study revealed two areas of mild narrowing in the mid and lower portions of your esophagus.

ASSESSMENT

Acute esophagitis.

PLAN

After reviewing the patient's examination and barium swallow findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have prescribed the patient Protonix 40 mg first thing in the morning to treat his acute esophagitis. I have also prescribed the patient Carafate 1 gram 4 times daily for 1 month to help coat the lining of his esophagus and stomach. I recommended a upper endoscopy for further evaluation. I have also advised him to change his diet, decrease alcohol, and caffeine. I have also advised him to avoid citrus foods, fruits, and spicy foods until his symptoms have improved. We discussed that he should eat slowly and chew his food thoroughly to avoid big pieces of food. All questions were answered.

INSTRUCTIONS

The patient will follow up with me in 1 week for his endoscopy.