Consult Gastroscopy Colonoscopy

DATE: [date of procedure] (Write as a single date, today's date.) PROCEDURE: "Gastroscopy and Colonoscopy" PRE-PROCEDURE DIAGNOSIS: [pre-procedure diagnosis and indications for the procedure] (Write as a list of brief points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) POST-PROCEDURE DIAGNOSIS: [post-procedure diagnosis] (Do not put in information in this section from historical endoscopy reports. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HISTORY OF PRESENTING ILLNESS: [description of the patient's presenting illness, including demographics, referral information, history of current symptoms, relevant past procedures, and recent clinical events] (Write in paragraphs of full sentences. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PAST GI HISTORY: [list of relevant past gastrointestinal diagnoses, procedures, and related conditions] (Write as a list of brief points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PAST HISTORY: [list of relevant past medical history, including chronic conditions, surgeries, and other significant health issues] (Write as a list of brief points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDICATIONS: [list of current medications, including dosage, strength, and route] (Write as a list of medications with details. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ALLERGIES: [list of known allergies or statement indicating no known allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) FAMILY HISTORY: [description of relevant family medical history, including specific diseases or conditions] (Write in paragraphs of full sentences. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SOCIAL HISTORY: [description of the patient's social history, including occupation, living situation, caregiver status, mobility, and history of tobacco, alcohol, or illicit substance use] (Write in paragraphs of full sentences. 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. Cardiovascular, respiratory, lymph node, and dermatological examinations were normal." INVESTIGATIONS: - [summary of relevant investigations, including dates and key findings from lab work, previous procedures, or imaging] (Write as a list of brief points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) CONSENT: "Informed consent was obtained after having reviewed the rationale and alternatives for the procedure as well as its risks, which include but are not limited to: sedation-related adverse effects, aspiration, post-procedural chest or abdominal discomfort, less than one percent risk of perforation with dilation potentially requiring surgical intervention and infection." SEDATION: "Intravenous conscious sedation consisting of midazolam [midazolam dose] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) mg and fentanyl [fentanyl dose] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) mcg." (Insert exactly from quotes. Do not put in information in this section from historical endoscopy reports) PROCEDURE: "Gastroscopy: After a time out, with the patient in the left lateral decubitus position, the gastroscope was inserted into the oropharynx and carefully advanced with direct visualization to the level of the cricopharyngeus. Esophageal intubation was performed without difficulty. The gastroscope was gradually advanced and the entire esophageal mucosa was carefully visualized. The gastroscope was further advanced into the stomach and the mucosa of the gastric fundus, body, and antrum were slowly surveyed. The gastroscope was subsequently advanced into the duodenum for evaluation of the first and second portions. Satisfactory mucosal views were achieved with the use of irrigation and suctioning of all pools of residue, mucus and fluid, and retroflection. The gastroscope was removed. The patient tolerated the procedure well. Colonoscopy: The patient was repositioned. Digital rectal examination was performed. An [colonoscope type] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) colonoscope was inserted into the rectum and advanced with the use of water insufflation and positional changes to the level of the cecal pole. Normal cecal pole landmarks were identified with clear visualization of the ileocecal valve and appendiceal orifice. Photographs were obtained. The colonoscope was carefully withdrawn. Satisfactory mucosal views were achieved with the use of dynamic positional changes, irrigation and suctioning of all pools of residue, mucus and fluid, segment reassessment, and retroflection. The colonoscope was removed and the patient was returned to the recovery room having tolerated the procedure well." QUALITY INDICATORS: "1. Bowel prep: [bowel preparation quality] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 2. Extent of examination: [extent of examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 3. Withdrawal time: [withdrawal time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) minutes 4. Technical difficulties: [technical difficulties] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 5. Unplanned events: [unplanned events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)" (Insert exactly from quotes. Do not put in information in this section from historical endoscopy reports) ASSESSMENT AND PLAN: [summary of assessment findings and the proposed plan, including follow-up, further investigations, and management strategies] (Write in paragraphs of full sentences. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)