GI Consult - Inpatient

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.