Date:
01 November 2024
I was called by Dr. Sarah Chen to see Mr. John Smith, and I was in the hospital assessing a previous patient, seeing him from 10:00 AM to 10:45 AM.
REASON FOR CONSULTATION
Chronic Abdominal Pain and Weight Loss
HISTORY OF PRESENTING ILLNESS:
Mr. John Smith, a 58-year-old male, was referred by Dr. Sarah Chen for evaluation of chronic abdominal pain and unintentional weight loss. The patient reports a 6-month history of diffuse, dull abdominal pain, predominantly postprandial, rated 5/10, occasionally sharp. The pain is exacerbated by fatty foods and partially relieved by antacids, though not consistently. He also reports an unintentional weight loss of 8 kg over the past 4 months. He experiences intermittent nausea but no vomiting. Bowel movements have become irregular, alternating between constipation (straining, hard stools) and occasional loose stools, occurring 3-4 times per week. No melena or hematochezia. He reports increased fatigue.
He has tried over-the-counter antacids and a bland diet, which provided minimal temporary relief. No previous endoscopic procedures for these symptoms.
PAST GI HISTORY:
Irritable Bowel Syndrome (diagnosed 10 years ago, managed with diet)
Hemigastrectomy (20 years ago for peptic ulcer disease)
PAST HISTORY:
Hypertension (managed with medication)
Type 2 Diabetes Mellitus (managed with oral hypoglycemics)
Cholecystectomy (5 years ago)
MEDICATIONS:
Lisinopril 10mg daily
Metformin 500mg twice daily
Omeprazole 20mg daily
Multivitamin daily
ALLERGIES:
Penicillin (hives)
FAMILY HISTORY:
Mother: Type 2 Diabetes, Hypertension
Father: Colon cancer (diagnosed at age 65)
Sister: Crohn's disease
SOCIAL HISTORY:
Patient is a retired mechanic. He smokes 1 pack per day for 30 years and consumes 2-3 units of alcohol per day. Denies illicit substance use. Lives with his wife. He enjoys gardening in his free time.
PHYSICAL EXAM:
The abdomen was soft, mildly tender in the epigastric region, with no hepatosplenomegaly or masses. Rectal examination was deferred. Cardiovascular, respiratory, dermatological, and lymph node examinations were normal.
INVESTIGATIONS:
- laboratory results: CBC normal, LFTs normal, Amylase/Lipase normal. CRP slightly elevated (8 mg/L).
- colonoscopy results: Previous colonoscopy 3 years ago was normal, no polyps found.
- upper endoscopy results: Not yet performed for current symptoms.
- imaging results: Abdominal ultrasound 2 months ago showed mild fatty liver, no gallstones or bile duct dilatation. CT abdomen/pelvis pending.
ASSESSMENT AND PLAN:
1. Chronic Abdominal Pain and Weight Loss
Assessment: Mr. Smith presents with chronic abdominal pain, unintentional weight loss, and changes in bowel habits, raising concern for a more significant gastrointestinal pathology than his previously diagnosed IBS, especially given his family history of colon cancer and current smoking status. Malignancy, pancreatic insufficiency, or severe inflammatory bowel disease are differential considerations.
Differential diagnosis: Pancreatic adenocarcinoma, Inflammatory Bowel Disease (Crohn's), Gastric malignancy, Malabsorption syndrome.
- Investigations planned: Urgent CT abdomen/pelvis (already pending). Refer for OesophagoGastroDuodenoscopy (OGD) with biopsies. Faecal elastase to assess for pancreatic exocrine insufficiency. Calprotectin to screen for intestinal inflammation. H. pylori stool antigen test.
- Medical treatment planned: Continue Omeprazole. Advise trial of pancreatic enzyme replacement therapy if faecal elastase is low. Nutritional counselling to address weight loss.
- Lifestyle modifications: Strongly advise smoking cessation and reduction in alcohol intake. Emphasise balanced, low-fat diet.
- Follow-up appointments: Review CT results and discuss OGD findings in 2 weeks. Follow-up with GP for smoking cessation support.
- Relevant referrals: Referral to oncology if malignancy confirmed.
Additional Notes]:
- Patient education on the diagnosed condition, including explanation of the condition, potential complications, and the importance of treatment adherence: Patient counselled on the potential seriousness of his symptoms, especially given weight loss and family history. Explained the need for further investigations to reach a definitive diagnosis. Emphasised the importance of attending all scheduled appointments and following lifestyle modification advice.
- Instructions for symptom monitoring and when to seek immediate care: Advised to seek immediate medical attention for severe abdominal pain, persistent vomiting, melena, or significant rectal bleeding.
- Any specific patient or family concerns addressed during the consultation: Patient expressed significant anxiety regarding the possibility of cancer, which was acknowledged and addressed with reassurance regarding thorough investigation and prompt management.
Date:
[insert date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
I was called by Dr. [put doctor's name here] to see [first name], and I was in the hospital assessing a previous patient, seeing [him/her] from [time of note creation to closest 15 min expressed as a 45 min range]. (Only include information for each placeholder in this sentence if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that is not mentioned.)
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 specific 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, nature of bowel movements, any 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 its 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 its 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 its 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, alcohol and tobacco cessation, 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 or recommendations for further evaluation or multidisciplinary care] (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.)
