Gastroenterology New Patient Consult

Reason for consultation: Dysphagia

History of Present Illness: 
Frank is a 75-year-old male who was last in his usual state of health until approximately one year ago, when he began experiencing dysphagia. There have been no recent hospitalizations. On assessment today, he reports that his symptoms began one year ago and have remained stable since onset. He describes difficulty swallowing primarily with solid foods, with no issues swallowing liquids. He is able to transfer food into his mouth and initiate swallowing, but experiences difficulty as the bolus progresses down the esophagus. He denies regurgitation, odynophagia, aspiration, chest pain, or respiratory symptoms. There is no history of gastrointestinal malignancy, Crohn's disease, inflammatory bowel disease, peptic ulcer disease, reflux esophagitis, liver disease, hepatitis, diverticulitis, diverticulosis, prior gastrointestinal surgery, colon cancer, gallbladder disease, stomach cancer, pancreatic diseases, pancreatic cancer, or esophageal cancer. He has not undergone any previous upper endoscopy or colonoscopy. There is no history of hematemesis, melena, hematochezia, jaundice, unexplained weight loss, anorexia, persistent nausea, vomiting, diarrhea, constipation, or heartburn. There is no family history of gastrointestinal malignancy or chronic gastrointestinal disease. He reports no impact on his ability to perform routine activities, including driving. His partner confirms his ability to drive and attend appointments. There is no mention of sleep disturbances, dietary changes, or psychological or cognitive symptoms related to his dysphagia.

Otherwise from a GI perspective they report no abdominal pain, nausea, vomiting, reflux, regurgitation, odynophagia, bloating, or early satiety. No hematemesis or melena. Bowel movements are regular. There is no pain with defecation. No hematochezia, mucus, or tenesmus. No fecal incontinence. No jaundice, pruritus, dark urine, or pale stools. No weight loss, fever, chills, or night sweats.

Past Medical History:
Dyslipidemia
Restless leg syndrome
Hypertension
Depression
Previous cervical fracture
Previous femoral fracture

Previous Endoscopies: 

Medications:
Alendronate, amlodipine, pramipexole, ramipril, rosuvastatin

Allergies:
NKDA

Social History:
He lives with his partner, who does not drive. He is able to drive himself and perform daily activities without limitations. Minimal alcohol use, no smoking, no recreational drug use

Family History:
No known family history of gastric malignancies, pancreatic disease, or inflammatory bowel disease

Physical Exam:
Deferred, Televisit

Assessment and Plan:
Frank is a 75-year-old male presenting with a one-year history of dysphagia to solids.

1. Dysphagia
Etiology likely secondary to esophageal narrowing or obstruction, multifactorial in nature, with possible contribution from medications such as alendronate and amlodipine. Differential includes benign esophageal stricture, medication-induced injury, and malignancy.

I will arrange an upper endoscopy to evaluate for esophageal narrowing, obstruction, or other pathology. The option of performing the procedure without sedation, using topical anesthesia to the throat, was discussed to allow the patient to drive himself to and from the appointment. No bowel preparation is required for the upper endoscopy; the patient was advised to maintain an empty stomach prior to the procedure if performed without sedation.

I discussed the procedure, rationale, and risks and benefits (including 1:1000 risk of complications including medication side effects, bleeding, perforation, missed lesion up to 20%). They were agreeable to proceed.

No dedicated GI follow-up has been arranged, I would be happy to see them sooner as required, they were given my office contact information and know to contact earlier.

Thank you for involving me in their care,

Samuel Bennett
Dr Samuel Bennett