GI Consult - General patient in person

Date: [insert date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) REASON FOR CONSULTATION [list the main diagnosis or problem discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HISTORY OF PRESENTING ILLNESS: [State the patient's name, age and gender and who the referring physician is.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Reason(s) for consultation, including relevant gastrointestinal concerns or symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Detailed history of the complaint(s), including duration, severity, aggravating and alleviating factors, associated symptoms, previous treatments, and responses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [detailed description of prior treatments, diets, medications used for their problem] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PAST GI HISTORY: [mention gastrointestinal medical history or surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Each separate issue on it's own line without a bullet.) PAST HISTORY: [mention medical history or surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Each separate issue on it's own line without a bullet.) MEDICATIONS: [mention medications and herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Each separate issue on it's own line without a bullet.) ALLERGIES: [mention allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) FAMILY HISTORY: [describe family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SOCIAL HISTORY: [describe social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [in social history include any mention of smoking, alcohol and substance use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [include any mention of employment or the work that the patient performs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PHYSICAL EXAM: [The abdomen was soft, non-tender, with no hepatosplenomegaly or masses. Rectal examination was deferred. Cardiovascular, respiratory, dermatological, and lymph node examinations were normal.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Alter text as needed based on context and any additional dictated information.) INVESTIGATIONS: - [laboratory results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [colonoscopy results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [upper endoscopy results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [imaging results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ASSESSMENT AND PLAN: [1. Gastrointestinal Issue or Condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Assessment, including the likely diagnosis and rationale based on subjective and objective findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Differential diagnosis, considering other potential gastrointestinal or systemic conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Investigations planned, specifying any additional endoscopic procedures, imaging, or tests needed for a definitive diagnosis or treatment planning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Medical treatment planned, detailing the type of medication, dosage, expected outcomes, and potential side effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Lifestyle modifications, including dietary advice, recommendations regarding alcohol and tobacco use, and physical activity recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Follow-up appointments, covering the expected timeline for review, monitoring response to treatment, and adjustment of management plans] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant referrals for further evaluation or multidisciplinary care if needed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [2. Additional Gastrointestinal Issues or Conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Follow the same structure as above for each additional issue or condition identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Additional Notes:] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Patient education on the diagnosed condition, including explanation of the condition, potential complications, and the importance of treatment adherence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Instructions for symptom monitoring and when to seek immediate care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Any specific patient or family concerns addressed during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (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.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)