Daniel DeMarco Focused H&P#6 Pediatrics

Chief Complaint: Dysphagia

 

History of Present Illness:

 

MA is an 18yo male with c/o dysphagia x 2 mos. When eating, he experiences the sensation that the food gets stuck. There are no factors that help alleviate the discomfort. Has been using Omeprazole and Carafate x 2 weeks with no improvement. Patient had EGD last week with biopsies which showed eosinophilic infiltration. Admits odynophagia. Denies fever, nausea, vomiting, diarrhea, weight loss.

 

Immunizations: UTD

Allergies: Seasonal, Eggs

Medications: Omeprazole 20mg PO qd, Carafate 1g PO qid

PMH: Denies

PSH: Denies

Social History

Home: Lives with mother, father, and brother at home. Mother and father are nonsmokers.

Drugs: Denies EtOH use, tobacco use, marijuana use, other illicit drug use.

Family History: Brother with Eosinophilic Esophagitis

 

Review of Systems:

General: Denies fever, anorexia, weight loss, weight gain, change in activity level 

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Admits dysphagia, odynophagia. Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, ear pain, sore throat

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, recent history of murmur, fainting, or dizziness with activity 

Respiratory: Denies cough, wheezing, shortness of breath

GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, hematochezia, or melena; describe stooling habits 

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae

Psychiatric: Denies HI/SI, hopelessness, helplessness.

 

Physical Exam:

Vital Signs:

BP: 106/66

Pulse: 64bpm

RR: 12 breaths/min

Temp: 37.0C

SpO2: 100%RA

Ht: 66.0 inches

Wt: 68kg

 

General Survey: Alert, NAD.

Skin: No petechiae, masses, lesions. No jaundice, cyanosis, mottling. No rashes.

Ears: External ear with no masses, lesions. Nontender to palpation. Auditory canal with no injection. B/L TMs pearly gray with cone of light in appropriate position.

Nose: Nares patent. Mucosa pink. Septum midline. Turbinates non-boggy, non-hyperemic.

Throat: Good dentition. Gingiva without lesions, masses. Uvula midline. No tonsillar swelling. 

Neck: Supple. No thyromegaly. No lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

Abdomen: Nondistended. BS +. Soft, non-tender. No guarding, rebound tenderness. No hepatosplenomegaly.

 

Assessment/Plan:

MA is an 18yo male with biopsy-confirmed eosinophilic esophagitis.

 

#Eosinophilic Esophagitis

– Start Fluticasone Propionate 220mcg inhaler, two sprays bid, swallowed

– Cont. Omeprazole 20mg PO qd

– Cont. Carafate 1g PO qid

– Dietary modification discussed and encouraged

 

Follow-Up: Return to clinic in 6 weeks

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student