Gastroenterology Consult

Patient Name: PATIENT_NAME

Date of Visit: SESSION_DATE

ID: [Patient ID]

CC: Lower abdominal pain, diarrhea with blood, fatigue, weight loss, and sleep disturbance.

HPI: PATIENT_NAME is a [age] year old female presenting to the clinic today for a gastroenterology consult. She reports experiencing lower abdominal pain for the past 4 months. The pain is described as intermittent, sharp and dull, and is located in the lower abdomen. She also reports frequent diarrhea, occurring daily, sometimes multiple times a day. The diarrhea is watery and accompanied by gas and bloating. She has noticed blood in her stool. She also reports fatigue, weight loss, and sleep disturbance. She believes her symptoms started after a business trip to India 4 months ago, suggesting possible food poisoning.

Symptoms:

• Gastrointestinal: Lower abdominal pain, diarrhea, hematochezia, bloating, gas
• Constitutional: Fatigue, weight loss, sleep disturbance

Physical Exam: Normal

Past Medical History:

• Asthma

Family History:

• Colon cancer (grandmother)

Medications:

• Asthma inhaler
• Over-the-counter antacid for heartburn

Investigations:

• Colonoscopy
• Blood test (liver function)
• Stool sample

Labwork:

• Stool Studies: Pending
• Liver Function Tests (LFTs): Pending

Gastrointestinal Symptoms:

• Abdominal Pain: Intermittent, sharp and dull, located in the lower abdomen.
• Diarrhea: Daily, sometimes multiple times a day, watery, accompanied by gas and bloating.
• Hematochezia: Present
• Bloating: Present
• Gas: Present

Dietary History:

• Patient is advised to keep a food diary to track her diet and its effect on her symptoms.

Gastrointestinal Endoscopy Findings: Pending

Gastrointestinal Procedures:

• Colonoscopy scheduled for next week.

Endoscopic Biopsy Results: Pending

Imaging Studies:

• None performed at this time.

Impression/Plan:

Diagnosis:

• Possible Inflammatory Bowel Disease (IBD): Given the patient's presentation of lower abdominal pain, diarrhea with blood, fatigue, and weight loss, IBD is a strong possibility.
• Possible Infectious Enteritis: The patient's travel history to India suggests possible food poisoning, which could be a cause of her symptoms.

Plan:

• Colonoscopy: To visualize the colon and obtain biopsies for histopathological examination to confirm or rule out IBD.
• Stool Studies: To evaluate for infectious causes of diarrhea.
• Liver Function Tests (LFTs): To assess liver function, which can be affected by IBD.
• Follow-up: After the results of the investigations are available, the patient will be scheduled for a follow-up appointment to discuss the findings and formulate a treatment plan.

Note: This report is based on the information provided in the transcript. Further investigations and evaluations are necessary to establish a definitive diagnosis and treatment plan.