POSTOPERATIVE DIAGNOSIS: Achalasia.

PROCEDURES PERFORMED:
1. Robotic-assisted laparoscopic Heller myotomy with Dor fundoplication.
2. Intraoperative endoscopy.
3. Intraoperative manometry.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 50 mL.

TUBES PLACED: An 18-French Foley catheter.

COMPLICATIONS: None apparent.

DISPOSITION: To the PACU.

CONDITION: The patient’s condition was stable.

INDICATIONS: This is a patient with an 8-month history of dysphagia and was recently diagnosed with achalasia based upon manometry as well as Barium swallow and it was recommended the patient undergo elective Heller myotomy with partial fundoplication utilizing intraoperative manometry guidance.

DESCRIPTION OF PROCEDURE: The patient was placed on the operating table in the supine position for Heller myotomy with partial fundoplication. Bilateral lower extremity compression boots were placed on the legs and turned on. General endotracheal anesthetic was administered.

The patient was positioned on the table in low lithotomy position with the legs in adjustable stirrups. Both arms were tucked by the side and an 18-French Foley catheter was placed with return of clear yellow urine. An endoscope was introduced through the mouth and passed down the esophagus. The esophagus was empty but had appearance consistent with achalasia.

The endoscope was passed into the stomach easily. The abdomen was prepped with ChloraPrep and draped with paper drapes, cloth towels, and a paper laparoscopy sheet. A time-out was taken to confirm the patient and the procedure. Antibiotics had been given within the hour. Compression boots were on and Foley catheter was draining clear yellow urine.

An umbilical puncture was made after infiltrating 0.5% Marcaine. A Veress needle was placed through the umbilicus. The intraperitoneal location of the tip of the needle was confirmed with a positive saline drop test and a low opening pressure of 4 mmHg.

The abdomen was insufflated to a pressure of 15 mmHg with low flow carbon dioxide insufflation upon which a 12 mm Xcel trocar was placed through the midline 17 cm below the xiphoid process with the laparoscope within the lumen of the trocar to place it under direct vision.

Once this was introduced into the abdominal cavity, anterior abdominal insufflation was maintained at a pressure of 15 mmHg with high flow carbon dioxide insufflation. Four additional trocars were then placed under direct vision.

A 5 mm trocar was placed along the patient’s right costal margin 17 cm from the xiphoid process. An 8 mm trocar was placed along the patient’s left costal margin 17 cm from the xiphoid process. Two operating trocars were placed 12 cm down from the xiphoid process and approximately 4 cm on either side of the midline. These were both 8 mm trocars as well.

Once all these trocars were placed, the patient was positioned in reverse Trendelenburg position and a 5 mm flexible liver retractor was passed through the right subcostal trocar and positioned under the lateral segment of the left lobe of the liver to expose the area of the GE junction.

The patient was noted to have a small hiatal hernia without any other abnormalities. Intraoperative manometry was carried out which revealed a very high pressure zone from 46 to 44 cm from the incisors. At this point, the robot was brought in and each of the arms were docked to the trocars and the robotic instruments were placed. Trocars were placed on the right and left side and a Harmonic scalpel was placed on the patient’s left side.

Attention was directed to the area of the GE junction. The cardia of the stomach was grasped and retraced downwards into the left and the phrenicoesophageal ligament was incised along the lesser curvature aspect of the stomach and held towards the diaphragm across anteriorly to expose the entire anterior esophagus, the right and left crural fibers of the diaphragm.

Once this was adequately cleared, the gastroesophageal fat pad was elevated and excised. Posteriorly, the confluence of the right and left crural fibers were identified and the hiatal hernia was repaired with a single 0 Ethibond suture tied intracorporeally.

At this point, attention was directed to the esophagus. This was treated with a concentrated epinephrine solution at the end of the Kitner sponge following which the fundoplication was begun. It should be noted that the manometry was carried out over a guidewire prior to placement of the manometry catheter.

The endoscope had been introduced into the duodenum. A guidewire was passed and the manometry catheter was placed over the guidewire. The manometry catheter and the endoscope were left in place in the esophagus and attention was directed to the esophageal muscles, which were incised utilizing a hook cautery dissector first incising the longitudinal muscle, and then circular muscle and heading a distance of approximately 6 cm proximally along the esophagus and down approximately 4 cm across the cardia until we were beyond the squamocolumnar junction as identified endoscopically.

In doing this dissection, a small incision was made into the esophageal mucosa which was repaired with a single figure-of-eight 4-0 Vicryl suture. This was later air tested with the endoscope and there was no evidence of any leakage from there or any other parts of the myotomy.

Once this was completed, repeat manometry revealed a decrease in the high pressure zone; although, there was still some pressure at the level around 46 cm. There were no additional muscular fibers. This was completely denuded down to mucosa.

At this point, a partial anterior fundoplication, Dor fundoplication, was created placing two sutures on the left side, one between the fundus, the left crus of the diaphragm and the left cut edge of the myotomy; approximately 2 cm below this, a second suture from the fundus to the left cut edge of the myotomy.

The area of the myotomy was then covered and then the fundus was rotated around the front of the mucosa and sutured placing two sutures between the fundus and the cut edge of the myotomy and the right crus and then two additional sutures between the fundus and the cut edge of the myotomy placing each of these approximately 2 cm apart to complete the anterior fundoplication.

All these sutures were placed intracorporeally with 2-0 Ethibond sutures. Once this was completed, the fundoplication was inspected and was in good position without any abnormal angulation.

The upper abdomen was irrigated with kanamycin saline solution. The robotic arms were disengaged and we went back to the laparoscopic view and the three 8 mm trocar sites as well as the 12 mm trocar sites were closed utilizing the transabdominal suture passer placing figure-of-eight sutures of 0 Vicryl in each of these under direct vision. Once these were all placed, the abdomen was desufflated and these were tied down.

The abdomen was reinsufflated and the closures were inspected through the 5 mm trocar and all these were airtight and intact. The abdomen was desufflated through the 5 mm trocar which was removed. The trocar sites were all closed with interrupted 3-0 Vicryl sutures and the skin was approximated with Dermabond dermal adhesive. The patient was transported to the PACU in stable condition.

REFERRING PHYSICIAN: Jane Doe, MD

REASON FOR CONSULTATION: History of gastroesophageal reflux disease, dysphagia, and vomiting.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who has a history of gastroesophageal reflux disease, of many years’ duration, chronic dysphagia with a history of esophageal stricture and possible esophageal pseudodiverticula, coronary artery disease, and status post CABG. The patient was admitted for persisting vomiting at home yesterday. As per the patient’s wife, he has had an EGD and esophageal dilation on him about three months ago by his primary gastroenterologist. He was told that he has a stricture in the esophagus with possible esophageal pseudodiverticula, and no further endoscopy was recommended by him three months ago.

The patient has had chronic dysphagia for the last five to six years, and he has had repeated esophageal dilations on him. Following the last dilation, three months ago, there was no further improvement in his dysphagia and is able to swallow soft food and liquids at this time. He has no history of choking. He does feel the food is slowly moving down the chest. He does not have any chest pain or abdominal pain. No history of GI bleed. He had persisting episodes of vomiting yesterday because of which he was brought to the ED. Following admission, he received intravenous hydration with Protonix and is able to swallow a clear liquid diet today. There is no recent history of weight loss. His bowel movements, otherwise, are regular. There is no history of blood in the stools.

PAST MEDICAL HISTORY: Significant for CABG and pacemaker placement.

MEDICATIONS: The patient is on Protonix, atenolol, and Ativan.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: The patient is married and he has one child.

SOCIAL HISTORY: The patient does not smoke, does not drink alcohol, and does not do any injection drugs.

REVIEW OF SYSTEMS: Otherwise, negative for other systems.

PHYSICAL EXAMINATION: The patient is a (XX)-year-old male who is alert and oriented x3. He is comfortable at rest. The patient’s vital signs include temperature of 98.2, heart rate of 60, blood pressure of 138/64, and respirations of 21. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. ENT examination is unremarkable. No JVD or lymphadenopathy appreciated. No thyromegaly. Neck is supple. First and second heart sound normally heard. No third sound, no fourth sound, and no murmur. Auscultation of the lungs showed bilateral vesicular breath sound. On examination of the abdomen, there is a soft and scaphoid abdomen. There is no tenderness in the abdomen. No hepatosplenomegaly appreciated. No ascites. Normal peristaltic sounds are heard. On examination of the extremities, no edema and no rash noted. The patient has no focal neurological deficits.

LABORATORY DATA: The patient had his labs three days ago, which showed a white blood count of 7.5, hemoglobin 10.6, and platelet count 192 with MCV 92. Electrolyte panel showed sodium 141, potassium 4.6, bicarbonate 24, chloride 108, BUN 26, creatinine 1.2, and glucose of 115.

ASSESSMENT AND PLAN:
1.  History of gastroesophageal reflux disease with chronic dysphagia with a possible esophageal stricture and esophageal pseudodiverticula. As per the patient’s wife, the patient has had an esophagogastroduodenoscopy with esophageal dilation on him three months ago, which did not help him with his dysphagia. At this point in time, he is able to swallow clear liquids and was able to swallow a full liquid diet at home. The patient did not have any further emesis after being admitted to the hospital. The patient and his family, at this time, were not interested in proceeding with any endoscopic evaluation on him. They want to take him to follow with his primary gastroenterologist. At this time, he is tolerating a clear liquid diet, which is to going to be advanced to full liquid diet and will be discontinued home in the a.m. tomorrow, if he tolerates the full liquid diet. Protonix is going to be changed to Prevacid liquid 30 mg p.o. daily at this time. The patient and his wife were informed about a possible feeding tube placement, in case he continues to have dysphagia, and the esophageal dilation cannot be accomplished because of the pseudodiverticula on him.
2.  Coronary artery disease, status post coronary artery bypass graft and pacemaker placement. Continue home medication.

PAST MEDICAL HISTORY:  The patient has had LASIK surgery to the eye. She has had a tummy tuck. She is known to have degenerative joint disease and osteopenia. No TB, diabetes.

ALLERGIES:  No known drug allergies.

CURRENT MEDICATIONS:
1.  Tums calcium two daily.
2.  Vitamin D3, 2000 units daily.
3.  Aspirin 81 mg daily.
4.  Cod liver oil daily.
5.  Celebrex 200 mg daily.

REVIEW OF SYSTEMS:
CARDIOVASCULAR: No angina, PND, orthopnea, claudication.
RESPIRATORY: No cough, sputum, hemoptysis, wheezing.
GENITOURINARY: She notes rare episodes of urinary stress incontinence.
MUSCULOSKELETAL: No acute arthritis. She has had some discomfort in her right knee and left shoulder.
CENTRAL NERVOUS SYSTEM: No headache, diplopia, seizures or focal weakness.

SOCIAL HISTORY:  The patient is a nonsmoker, social drinker. She has been under some stress. She walks three times per week. Her diet is well balanced.

FAMILY HISTORY:  Unremarkable for colonic neoplasm.

PHYSICAL EXAMINATION:
GENERAL: The patient is in no acute distress. She appears much younger than stated age.
VITAL SIGNS: Weight 106 pounds; pulse 72 per minute, regular; BP 142/76 in the right arm; respirations 18 per minute.
HEENT: No pallor, icterus, lymphadenopathy. Normocephalic. Pupils react to direct light. Throat is clear. Tongue is well papillated.
NECK: Thyroid without masses. No carotid bruits.
HEART: Normal first and second heart sounds. No murmurs, clicks, S3 or rubs.
RESPIRATORY: Trachea central. No dullness. Good air entry without rales or rhonchi.
ABDOMEN: Soft. No tenderness, guarding, hepatosplenomegaly, masses or ascites. Bowel sounds are normal. Inguinal hernial sites intact. Scar of tummy tuck noted, horizontal incision in the abdomen.
RECTAL: Slight erythema is noted around the anal verge. One perianal skin tag is noted. No rectal masses palpable. Burgundy stool, strongly Hemoccult positive, is noted on finger cot.
NEUROLOGIC: Cranial nerves II through XII intact. Reflexes present and equal. Coordination intact.
MUSCULOSKELETAL: Slight limited range of rotatory movements of the neck. Good range of motion of the hips. Good foot pulses. No clubbing or cyanosis.

IMPRESSION:
1.  Chronic hematochezia with likely causes including:
a.  Rule out bleeding diverticulosis coli.
b.  Rule out bleeding colonic neoplasm.
c.  Doubt bleeding internal hemorrhoid.
d.  Doubt inflammatory bowel disease.
2.  History of colonic polyp.
3.  Tendency to constipation, functional, possibly related to chronic hematochezia.
4.  Suspect degenerative joint disease, right knee, mild severity.

PLAN:
1.  Reassurance, explanation.
2.  To check CBC, sed rate, comprehensive metabolic panel, and TSH.
3.  To proceed with colonoscopy, possible biopsy, possible polypectomy.
4.  To review previous records.
5.  To discontinue aspirin at this time.
6.  Probiotic Align one daily.
7.  Further treatment will depend on findings of above studies. Close followup.

PREOPERATIVE DIAGNOSIS AND INDICATIONS: A patient with a long history of Crohn’s of the upper GI tract, status post multiple upper GI-related surgeries over nine years ago. Now, the patient has had a slow weight loss with poor nutrition with several significant strictures noted just beyond the stomach in the proximal jejunum.

POSTOPERATIVE DIAGNOSIS: Multiple Crohn’s-related strictures just distal to the stomach. The patient also had postsurgical changes. The significant strictures were dilated to 36 French with what was felt to be good results.

PROCEDURE PERFORMED: Panendoscopy and dilation.

MEDICATIONS: Fentanyl 200 mcg and Versed 2 mg.

DESCRIPTION OF PROCEDURE AND FINDINGS: The risks and indications of the procedure were discussed with the patient, who understood the risks and agreed to the procedure.

After sedation, the video endoscope was visually passed through the mouth into the esophagus. The esophagus was closely examined and revealed no abnormalities. The scope was passed into the stomach. There was some liquid and food debris in the stomach. The patient was status post antrectomy. His anatomy appeared to be most consistent with a Billroth II with afferent and efferent loops.

The area just past the stomach, which was felt to be jejunum, was markedly dilated. There was a stricture that was noted in this dilated segment. The scope was able to get through this stricture into a second dilated pouch of jejunum. There again was a second tight stricture in this area also.

With some manipulation, the scope was able to pass through this stricture and advanced another 10 or 15 cm. There was a third milder stricture, and then, when the scope was fully advanced to its limit, there did appear to be a mild to moderate fourth stricture. A wire and dilating balloon were able to easily pass beyond the fourth stricture. Initially, the fourth stricture was dilated to 30 French. The scope and balloon were then withdrawn, and dilation of the second stricture was also performed to 30 French.

At this point, the scope was further withdrawn, and the first most proximal stricture was dilated to 30 French. The scope was then advanced down to the fourth stricture. It was somewhat difficult to advance the scope beyond this for stricture. This was mostly related to tortuosity of the jejunum. Dilation was performed to 33 French.

At this point, the position of the scope was somewhat lost and no further dilation of the stricture was performed. The second stricture was next dilated again to 33 French and then 36 French. The scope was then further withdrawn and the most proximal stricture dilated to 33 French and 36 French. There did seem to be some significant improvement in these strictures. No complications were noted during the dilation. The procedure was then completed, and the patient’s immediate recovery was uneventful.

PLAN AND RECOMMENDATIONS: The patient was started on a clear liquid diet and slowly advance his diet. We will probably repeat the endoscopy and consider further dilation in six to eight weeks.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Anemia.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old woman who was admitted to the hospital yesterday with worsening anemia. She has longstanding anemia felt to be secondary to a combination of iron deficiency, hemolysis, and anemia of chronic disease. She has been on oral iron therapy at home as well as Procrit injections. Despite all these measures, her hemoglobin was noted to be declining. She has not had any recent change in her bowel habits or seen any blood in her stool.

She denies anorexia, weight loss, nausea, vomiting or abdominal pain. She has a history of colon polyps and her last complete colonoscopy was eight years ago with diverticulosis and hemorrhoids but no polyps. She did have a flexible sigmoidoscopy three years ago that was significant only for hemorrhoids.

Her last EGD was eight years ago at which time she was noted to have small gastric polyps and duodenal diverticulum. Since being admitted to the hospital, she has been transfused one unit of blood. Her hemoglobin on admission was 6.6. A repeat hemoglobin is currently pending.

PAST MEDICAL HISTORY: As above, coronary artery disease, aortic stenosis, atrial fibrillation, anemia, mesenteric ischemia, hypertension, and hypercholesterolemia.

PAST SURGICAL HISTORY: CABG, mitral valve replacement, cataracts, carotid endarterectomy, rotator cuff surgery, surgery for ectopic pregnancy, hemorrhoidectomy, superior mesenteric artery stent, and exploratory laparotomy with lysis of adhesions.

ALLERGIES: Multiple, listed in the chart.

HOME MEDICATIONS: Atenolol, biotin, Coumadin, digoxin, FoliTab, Librium, Lipitor, magnesium oxide, Procrit, Protonix, Vasotec, and vitamin D.

SOCIAL HISTORY: Previous tobacco. No alcohol. No illicits.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS:
GENERAL: The patient denies fevers or chills.
HEENT: Denies vision problems or hearing problems.
CARDIOVASCULAR: Denies chest pain or irregular heartbeats.
RESPIRATORY: No cough, shortness of breath, hemoptysis or wheezing.
GASTROINTESTINAL: See HPI.
MUSCULOSKELETAL: She denies joint or muscle pain, aches or inflammation.
NEUROLOGIC: She denies headaches or focal neurologic defects.
PSYCHIATRIC: She denies change in mood, affect or behavior.
HEMATOLOGIC: She denies abnormal bruising or bleeding.
ALLERGIC/IMMUNOLOGIC: She denies unexplained or recurrent infections.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, pulse 90, respirations 18, and blood pressure 142/76.
GENERAL: The patient is well developed, well nourished, in no acute distress.
HEENT: Pupils are equal and round. Oropharynx is clear.
HEART: Regular rate and rhythm. Systolic ejection murmur is present.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, nondistended.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Motor and sensory grossly intact.

LABORATORY DATA: Hemoglobin 6.6 on admission. Repeat hemoglobin currently pending. INR 2.54.

IMPRESSION:
1.  Anemia.
2.  History of colon polyps.

PLAN:  We are currently awaiting her repeat hemoglobin level from today. We will continue to give her blood transfusion until her hemoglobin level is over 8. We will also give her one dose of vitamin K 10 mg orally. We will place 2 units of fresh frozen plasma on hold. We will continue her on IV Protonix. We will plan on doing an EGD and colonoscopy tomorrow with monitored anesthesia care for further evaluation. The risks, benefits, and alternatives to the procedure were explained to the patient. She expressed understanding. Further recommendations will follow after the endoscopic procedures are completed.

CHIEF COMPLAINT: Abdominal discomfort.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman with multiple medical problems, including hypertension, high cholesterol, gastroesophageal reflux disease, incontinence, allergies, back pain, morbid obesity, and recent evaluation of the eyes who comes in for evaluation of abdominal discomfort.

The patient states that the symptoms started in the fall. The reason why she is here is because they seem more frequent and persistent. She states that she would have these sporadic episodes of diffuse abdominal discomfort, which would last anywhere from one to two hours associated with nausea. She had vomiting with it as well and then it would just go away. She might not have it for days or weeks and then it would just come back out of nowhere.

She had an episode today and then she had it three days ago. She feels it is just getting worse, and she is getting concerned. She does not have diarrhea, but she did have episodes of vomiting. It is not severe, but she definitely has the discomfort. Nothing makes it better. Nothing makes it worse. She does not feel that it is associated with food. It will just come, stay with her for a few hours, make her sick, and then it would go away.

PAST MEDICAL HISTORY: Hypertension, high cholesterol, gastroesophageal reflux disease, incontinence, allergies, back pain, and obesity.

MEDICATIONS: Atenolol 100 mg daily, doxazosin 4 mg daily, Dyazide 25 mg, omeprazole 20 mg, Lipitor 20 mg, Flonase, doxycycline 100 mg daily since late summer, multivitamin, iron, Probiotica, and Lasix.

PHYSICAL EXAMINATION: Blood pressure 140/82, heart rate 78. In general, she is not in acute distress, but she is a little fatigued appearing. Heart: S1, S2. Lungs are clear. Abdomen: Obese. She has bowel sounds. She did have some diffuse tenderness to palpation in her lower abdomen.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old woman who comes in for evaluation of abdominal discomfort. The abdominal discomfort has been present for months, getting more frequent, associated with some nausea and vomiting. No diarrhea. Not related to food. The patient already had a cholecystectomy.

Differential diagnosis would include gastritis, side effects of the doxycycline, possibly colitis. For now, we will take a CT of the abdomen and pelvis. We will change her Prilosec to Nexium.

The patient is also going to discuss it with her doctor to try to substitute the doxycycline with a different antibiotic or possibly put it on hold. If it turns out that the patient feels better off the antibiotic, that would be reassuring to know the etiology of her symptoms. The patient states that unless it gets worse, she is willing to stay on the antibiotic and just bear with the symptoms.

PREOPERATIVE DIAGNOSES:
1.  Bright red blood per rectum.
2.  Gastrointestinal bleeding.
3.  Anemia requiring transfusion.

POSTOPERATIVE DIAGNOSIS:  Pandiverticulosis of the colon.

PROCEDURE PERFORMED:  Colonoscopy.

ANESTHETIC:  Sedation.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  None.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female with a history of bright red blood and melena. Her hemoglobin on admission was less than 7.4. She required transfusion. She was placed in the ICU. The bleeding apparently slowed, and she reported a colonoscopy over five years ago with history of diverticulosis but no history of bleeding or diverticulitis. We consented her for colonoscopy.

DESCRIPTION OF PROCEDURE:  The patient was brought into the endoscopy suite. She was attached to all appropriate monitoring equipment. IV sedation was administered. She was positioned in the left lateral decubitus position. A rectal exam was performed. Rectal tone was normal. There were no abscesses or fissures. She had atrophic hemorrhoidal tags.

Once rectal exam was completed, a well-lubricated video colonoscope was advanced into the rectal vault. The patient was noted to have poor prep with greenish stool coating all surfaces of the mucosa and occasional small pieces of fecal material. The scope was advanced beyond this initial finding and irrigation/aspiration was performed as the scope was advanced into the sigmoid colon. Multiple wide-mouthed diverticula. No evidence of bleeding was encountered. The descending and transverse colon were cannulated. Multiple diverticula but no polyps, tumors or evidence of bleeding. The right colon was also cannulated; however, we were unable to manipulate the scope into the cecum.

The scope was used to irrigate and wash all mucosal surfaces and slowly withdraw the scope while inspecting these surfaces. No abnormalities other than the above-mentioned diverticulosis were found. There was no evidence of any bleeding. No polyps. No tumors. No AV malformations.

The scope was then withdrawn back through the transverse, descending, and sigmoid colons. Photographic documentation of the diverticula was obtained. The scope was retroflexed in the rectal vault and mild, noninflamed, nonbleeding hemorrhoids were noted. The scope was then used to decompress the colon.

The patient was allowed to awaken. She tolerated the procedure well. There were no complications.

IMPRESSION:  Colonoscopy with pandiverticulosis and mild internal hemorrhoids.

RECOMMENDATIONS:  Resume high-fiber diet. Avoid nuts and seeds. Iron replacement. Follow up p.r.n. and/or recurrent bleeding.

HISTORY OF PRESENT ILLNESS: Today, we had the pleasure of seeing this patient in the gastroenterology clinic. He is a (XX)-year-old male who presents here for further evaluation. He was initially seen two months ago for a food impaction and was found to have an esophageal stricture, which was again complicated in the mediastinum anterior to the trachea. The patient was managed conservatively and was discharged. Now, he presents here with solid food dysphagia and also is receiving treatment for his lung cancer. The patient denies any pain on swallowing, fever or chills, change in medication.

PAST MEDICAL HISTORY: Thrombocytopenia and diabetes type 1, chronic kidney disease, non-small cell lung cancer N2M0 confirmed by biopsy of the mediastinal nodes three months ago.

PAST SURGICAL HISTORY: Benign esophageal stricture status post dilation x2, endoscopic right carotid endarterectomy, epidermal inclusion cyst, flexible bronchoscopy with medistinal washings and a PET positive lymph node in the mediastinum.

SOCIAL HISTORY: The patient has a 60-pack-year history of smoking and was drinking about 2-3 beers per day but has cut back, former smoker, episodic alcohol use, and no illicit drugs.

FAMILY HISTORY: Father had stomach cancer.

REVIEW OF SYSTEMS: All other review of systems otherwise negative.

PHYSICAL EXAMINATION:
GENERAL: Reveals a healthy-appearing, pleasant male in no acute distress.
VITAL SIGNS: Reviewed. BMI is 22.
HEART: S1, S2 heard.
LUNGS: Bilateral air entry good, clear and no crepitus.
ABDOMEN: Soft, nontender, bowel sounds positive.
EXTREMITIES: No edema, positive pulses.
PSYCHIATRY: Appropriate mood and affect.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old male with esophageal stricture status post food impaction and mild amount of pneumomediastinum about two months ago. At this point, we would schedule the patient for an upper endoscopy and possible dilation. The etiology for his dysphagia could be multifactorial, could be related to infectious etiologies suggestive of Candida or other etiologies such as radiation or malignancy are possible and can be excluded with an upper endoscopy and dilation plus or minus biopsies if needed. It has to be noted that the recent CAT scan did not show any esophageal mass. The patient will be scheduled for an upper endoscopy under general anesthesia for further treatment.

CHIEF COMPLAINT: Left lower quadrant pain.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant, otherwise healthy gentleman who has left lower quadrant pain for about five days. The patient stated that he had a colonoscopy done five days ago. He states that he did have some cramping abdominal pain before the colonoscopy, but it has been gradually worsening over the past five days. It is cramping in nature. It is rated a 5/10 in severity.

The patient states that it does not radiate. It is not improved with anything. It is worse when he lifts up his left leg. He states he has been able to work for the last several days. He denies any fevers. He denies any vomiting and denies any diarrhea. The patient states he is having normal bowel movements with no blood, and he is tolerating p.o.

PAST MEDICAL HISTORY: Significant for anxiety and atrial fibrillation.

PAST SURGICAL HISTORY: None.

MEDICATIONS: Aspirin and metoprolol.

ALLERGIES: Penicillin.

SOCIAL HISTORY: The patient denies any tobacco, alcohol or drugs.

REVIEW OF SYSTEMS: Constitutional and GI as per HPI. Otherwise, 10-point review of systems was done and is negative.

PHYSICAL EXAMINATION:
GENERAL: The patient is well appearing, nontoxic, alert and oriented x4. GCS 15.
VITAL SIGNS: Blood pressure is 124/84, pulse is 86, respiratory rate is 16, temperature is 37.2, and saturation is 100% on room air, which is normal.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Oropharynx is benign with moist mucous membranes.
NECK: Supple. Full range of motion. No meningismus.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, mildly tender to palpation in the left lower quadrant. No rebound, no guarding. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: No rash, petechiae or purpura.
NEUROLOGIC: Cranial nerves II through XII are grossly intact. Strength is 5/5 x4 extremities. Sensation is intact to light touch distally.

EMERGENCY DEPARTMENT COURSE:  The patient was seen and examined. He was admitted to the emergency room for observation. The patient did not wish to have any pain medication in the emergency room. He stated that his pain was well controlled. He had a laboratory workup; the results were interpreted by us. CBC was within normal limits with a white blood cell count of 10.2; although, he did have a neutrophilia of 83%. Absolute neutrophil count was mildly elevated. His complete metabolic panel was normal. His coag studies were normal. Urinalysis was negative.

We discussed the case with Dr. John Doe of the GI service. He was able to review the patient’s colonoscopy. He stated that he did not have any polypectomy; however, he did have some sigmoid diverticular disease, and the physician that did the study felt that there was a little bit of edema.

He felt that it is possible that this is just pain resulting from dilation of the colon, but it is also possible this is the beginning of a mild diverticulitis, and he did recommend treating. The patient does not have any peritonitis to make us concerned that there is an abscess, and therefore, we do feel he is stable for outpatient treatment.

MEDICAL DECISION MAKING:  The patient is very pleasant. He has left lower quadrant pain for five days. The differential diagnosis considered after he had the colonoscopy was a perforated viscus. The patient did not have any peritonitis. He had an x-ray that did not show any free air, and we are not concerned that he had a perforation of his colon at this time, as he is nontoxic and well appearing.

This could have been just pain from gas dilation of his colon, but given the history by Dr. John Doe, we do feel the patient needs to be treated for mild diverticulitis. There is no concern for an abscess at this time. The patient does not need inpatient treatment and can safely be discharged home.

DISPOSITION:  Home.

CONDITION:  Stable.

DIAGNOSES:  Diverticulitis and left lower quadrant pain.

INDICATION FOR PROCEDURE:  Cerebellar tumor resection complicated by postoperative hydrocephalus and recurrent aspiration pneumonia with inability to initiate oral feedings without significant aspiration.

DESCRIPTION OF PROCEDURE:  Prior to the procedure, 3 mg of Versed and 25 mcg of fentanyl were given intravenously. The patient was laid in a prone position. Betadine was used to clean the anticipated target area in the epigastric region. The abdomen was thoroughly examined and noted to be free of scars and was soft with favorable appearance to proceed.

The adult gastroscope was inserted into the mouth and advanced to the second portion of the duodenum. The mucosa was carefully examined in the duodenum, stomach, and esophagus. No significant lesions were noted. The scope was used to transilluminate the abdominal wall. A finger was placed on the patient’s abdomen and a pressure applied demonstrating adequate indentation of the stomach wall visualized via the endoscope.

The area was once again cleaned with Betadine solution. A sterile drape was placed over the patient. Five mL of lidocaine without epinephrine was drawn up in a syringe. A small wheal was placed in the patient’s skin for local anesthesia. The finder needle was inserted perpendicular to the skin at an angle previously noted to be appropriate as per this endoscopic visualization. Aspiration with injection of lidocaine was performed on a tract into the stomach. Bubbles were noted in the syringe upon reaching the stomach.

The finder needle was then withdrawn. The trocar catheter assembly was then inserted into the abdominal wall utilizing the same technique. Bubbles were aspirated upon reaching the stomach lumen. The blue wire was passed through the trocar into the stomach. A snare was passed down the endoscope and used to ensnare the blue wire. The scope and the wire were removed from the patient.

A small cut was made in the surface of the skin adjacent to the wire to allow for passage of the PEG tube. The wire was removed from the snare, and a wire was attached to the PEG tube and secured. The operator pulled the wire through the wall of the abdomen pulling the PEG tube down the esophagus into the stomach and out the abdominal wall as expected.

The gastroscope was reinserted and used to visualize placement of the PEG tube. The tube was noted to be in appropriate position. The tube was clipped and the appropriate holding devices put in place and clamped. The patient recovered without event.

ASSESSMENT:  Successful placement of percutaneous endoscopic gastrostomy tube.

RECOMMENDATIONS:
1.  One gram Ancef IV to be given upon arrival.
2.  Okay to start using PEG tube in 4 to 6 hours.
3.  Nutrition consult to help with tube feed directions.
4.  Standard PEG tube instructions to apply.