Chief Complaint: EGD Consult

History of Present Illness:
Pt name removed is a age removed Years Old sex removed who presents today for diagnostic EGD evaluation.

Since July 2018 he/she has felt a lump in his/her throat that feels like "a chip stuck sideways". Onset without trauma or illness. The sensatation never goes away fully, and is made worse by swallowing liquids and pressing on his/her neck. Several times per week he/she has trouble getting fluids down because of the sensation, but is otherwise eating and drinking well. No personal hx of cancer, no fevers, chills weight loss. No hx or trauma or surgery to neck. No current tobacco/alcohol use. Recent thyroid workup including thryoid US negative. Pt endorses moderate to severe heartburn over the last 10 years, worse with lying flat. He/She has not tried antacid medication. He/she is also experiencing exercise-induced SOB with chronic non-productive cough over the last few months and having to use albuterol inhaler for asthma after years of not needing medication.

The patient was referred by: removed
Indication(s): globus with liquid>solid dysphagia

Previous EGD / Colonoscopy: None
Personal GI History: Heartburn for last 10 years, frequent childhood Strep throat infxns
Family History of Colon/GI Disease / Cancer: none

Anesthesia Concerns: None
ASA Class: II (asthma)
Bleeding Risks Noted: None

I have explained the prep and procedure in detail with the patient and answered all questions. The patient is willing for me to perform their EGD with or without biopsy using conscious sedation. They also agree to the risks as I have explained them which include, but are not limited to, excessive bleeding, pain, infection, adverse anesthesia reaction and/or colonic perforation.

Problem List Changes:
Added new problem of Globus sensation (ICD-306.4) (ICD10-F45.8)
Added new problem of GERD (ICD-530.81) (ICD10-K21.9)
Added new problem of Asthma (ICD-493.90) (ICD10-J45.909)
Changed problem from Body mass index (BMI) 32.0-32.9, adult (ICD-V85.32) (ICD10-Z68.32) to Body mass index (BMI) 33.0-33.9, adult (ICD-V85.32) (ICD10-Z68.33)
Assessed Globus sensation as new
Assessed Asthma as unchanged
Assessed GERD as unchanged

Medication List: (Reviewed and Updated)
OMEPRAZOLE 40 MG ORAL CAPSULE DELAYED RELEASE (OMEPRAZOLE) Take one by mouth daily
PROAIR HFA 108 (90 BASE) MCG/ACT INHALATION AEROSOL SOLUTION (ALBUTEROL SULFATE) two puffs q4 hours prn
NORGEST/E ES TRIPHASIC PK 28 (NORGESTIM-ETH ESTRAD TRIPHASIC) TAKE 1 TABLET DAILY (NEED APPOINTMENT)
IMITREX 50 MG ORAL TABLET (SUMATRIPTAN SUCCINATE) one po at onset of HA may repeat in 1 hrs if needed.

Allergy List: (Reviewed and Updated)
ERYTHROMYCIN (ERYTHROMYCIN OINT) (Critical)
SHELL FISH (Critical)
HIBICLENS (CHLORHEXIDINE GLUCONATE LIQD) (Critical)
CONTI CASTILE SOAP (SOAP & CLEANSERS) (Critical)
IODINE (Critical)

Medical History: (Reviewed and Updated)
chronic HA
acid reflux

Surgical History: (Reviewed and Updated)
none

Social History: (Reviewed and Updated)
Drug Use – no
HIV/High Risk – no
Regular Exercise – yes

Smoking History:
Patient is a former smoker.

Family History: (Reviewed and Updated)
Sister – Hypothryoidism
Aunt: BRCA positive

Sexual History: (Reviewed and Updated)
Last Menstrual Period: removed

Risk Factors:
Tobacco: (Reviewed and Updated)

Review of Systems:
All other systems reviewed and are negative

General: Denies fever, chills.
Cardio: Denies chest pain, palpitations.
Respiratory: Denies SOB, cough.
GI: COMPLAINS OF HEARTBURN, FREQUENT INDIGESTION, DIFFICULTY SWALLOWING. Denies abdominal pain, vomiting, diarrhea, nausea, constipation, blood in stools, dark stools.

Vital Signs:
Weight: 179.8 lbs. (81.73 Kg.) Height: 62 in. (157.48 cm.) BMI: 33.00
Temperature: 98.6 deg F. (37 deg C.) Temperature Site: Temporal
Respiration: 16 Pulse: 74 Pulse Rhythm: Regular
Blood Pressure #1: 122/72 mm Hg. Location: Lt Arm Position: sitting
Entered by: removed

Physical Exam:
General: Well developed, well groomed, in no acute distress.
Head: Normocephalic/atraumatic.
Mouth: Mucus membranes moist; Uvula midline; oropharynx mildly erythematous
Neck: Supple; No thyromegaly or nodules.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Psych: Alert and oriented. Judgement and insight intact.

Assessment and Plan:

• GLOBUS SENSATION (ICD-306.4) (ICD10-F45.8) New
Suspicious for GERD-induced globus in context of cough, worsening asthma, and regular heartburn. Relative lack of solid dysphagia reassuring. Ddx includes esophageal dysmotility, eosinophilic esophagitis, globus hystericus, esophageal cancer. Diagnostic EGD reasonable at this time. Will try trial of omeprazole 40mg as well. Pt consented today.

• ASTHMA (ICD-493.90) (ICD10-J45.909) Unchanged
Using albuterol inhaler several times weekly. Monitor for improvement with anti-acid therapy.

• GERD (ICD-530.81) (ICD10-K21.9) Unchanged
Pt has suffered with regular heartburn since the birth of her son. Could be causing globus sensation, cough, and worsening asthma. Trial of omeprazole 40mg po daily.

Medication List Changes:
Added new medication of OMEPRAZOLE 40 MG ORAL CAPSULE DELAYED RELEASE (OMEPRAZOLE) Take one by mouth daily; Route: ORAL Indications: DYSPHAGIA, OROPHARYNGEAL PHASE – Signed

Rx of OMEPRAZOLE 40 MG ORAL CAPSULE DELAYED RELEASE (OMEPRAZOLE) Take one by mouth daily; Route: ORAL #30[Capsule] x 3; provider and pharmacy removed

Orders:
Est. Level 5: Complete [CPT-99215][/COLOR]