Compte rendu gastro-entérologue

**<u>Gastroenterologist Consultation Report</u>** **_Reason for consultation:_** [main reason for the gastroenterology consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) **_Medical history:_** • Gastroenterological history: [relevant digestive medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • Surgical history: [relevant abdominal or digestive surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • Other medical history: [other relevant medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **_Family history:_** • [family history related to digestive diseases or malignancies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) **_Current treatments:_** • [current medications with dosage information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) **_History of the present illness:_** • [timeline and evolution of the current symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) **_Digestive symptoms:_** • Abdominal pain: [clinical characteristics of abdominal pain] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • Bowel habits: [changes in bowel movements or stool pattern] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • Other digestive symptoms: [additional digestive complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **_Clinical examination:_** • General condition: [general physical status and anthropometric data] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • Abdominal examination: [findings from abdominal physical examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • Other examinations: [findings from other relevant physical examinations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **_Additional investigations:_** • Laboratory tests: [relevant laboratory investigation results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) • Imaging: [diagnostic imaging investigations and results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) • Endoscopy: [endoscopic investigations and related findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) **_Diagnosis:_** • [confirmed diagnosis and differential diagnostic considerations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) **_Therapeutic plan:_** • Medication treatment: [pharmacological treatment plan with dosage and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) • Lifestyle and dietary measures: [recommended lifestyle or dietary modifications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) • Investigations to schedule: [planned follow-up investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) **_Follow-up:_** • [follow-up plan and timing of next consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Present as bullet points.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)