Thank you for referring John, a teacher, for review of chronic abdominal pain.
Issues:
1. Chronic abdominal pain
2. Dyspepsia
Medication List:
Omeprazole 20mg daily, paracetamol as needed.
Recommendations:
1. Consider upper endoscopy.
2. Advise on dietary modifications.
Consultation Summary:
John presented with a several-month history of intermittent, crampy abdominal pain, primarily in the epigastric region. He also reports frequent episodes of dyspepsia, including heartburn and acid reflux. The pain is often triggered by meals, particularly those high in fat. He denies any changes in bowel habits, weight loss, or GI bleeding. He has tried over-the-counter antacids with limited relief. Past medical history is unremarkable. He does not smoke, drinks alcohol occasionally, and has no known allergies.
Examination Findings and Results:
- Vitals: BP 130/80, HR 78, RR 16, Temp 37.0°C
- Physical examination findings, especially abdominal exam: Mild tenderness to palpation in the epigastric region, no guarding or rebound tenderness. Bowel sounds were normoactive.
- Investigation results including imaging (CT, MRI, US), endoscopic findings, lab tests (LFTs, CBC, inflammatory markers): Blood tests were within normal limits.
Intestinal Ultrasound:
State that intestinal ultrasound was performed with patient consent
Include probe details: XX linear and YY curved
Detailed findings by segment including bowel wall thickness (mm), Doppler signal presence and pattern, bowel wall stratification, mesenteric hyperechogenicity, peristalsis, upstream diameter.
Colonic findings including segmental bowel diameter, contents, haustra coli presence, acoustic shadowing.
IUS Metrics:
- Most affected segment: Proximal jejunum
- Max bowel wall thickness in mm: 3.2mm
- Colour Doppler signal grade (0–3): 1
- Mesenteric i-fat: absent
- Bowel wall stratification: present
- Max right colon diameter: 4.1cm
- Haustra coli: present
- Posterior acoustic shadowing: present
Summary of IUS findings: Mildly increased bowel wall thickness in the proximal jejunum, with normal peristalsis and no evidence of significant inflammation.
Assessment & Plan:
1. Gastrointestinal Issue or Condition
- Assessment including likely diagnosis and rationale: Likely functional dyspepsia, given the symptoms and normal blood tests. Rule out other causes with further investigations.
- Differential diagnosis: Peptic ulcer disease, gastritis, irritable bowel syndrome.
- Planned investigations: Upper endoscopy.
- Medical treatment plan: Continue omeprazole 20mg daily. Consider adding a prokinetic agent if symptoms persist. Discuss the potential side effects of the medication.
- Lifestyle advice: Advise John to avoid trigger foods, eat smaller meals, and avoid eating late at night. Encourage regular exercise.
- Planned follow-up timeline and purpose: Follow-up in 4 weeks to review symptoms and endoscopy results.
- Referrals made or planned: None.
2. Additional GI Issue or Condition
- Repeat above structure as needed for additional conditions
Additional Notes:
- Patient education provided: Discussed the nature of functional dyspepsia and the importance of lifestyle modifications.
- Symptom monitoring advice and warning signs to seek urgent care: Advised John to seek immediate medical attention if he develops severe abdominal pain, bloody stools, or significant weight loss.
- Any patient or family concerns discussed: John expressed concerns about the potential for a serious underlying condition, which was addressed.
Endoscopy Plan:
Pre-Procedure Instructions:
Dietary, medication and prep instructions: Patient to fast for 8 hours prior to the procedure. Stop omeprazole 1 week before the procedure.
Procedure Details:
Type of endoscopy, date/time, location: Upper endoscopy, 15 November 2024, 10:00 AM, Endoscopy Suite.
Consent:
Details of informed consent process including risks discussed: Risks and benefits of the procedure were discussed with John, and informed consent was obtained.
Post-Procedure Care:
Diet/activity instructions, follow-up timeline: Clear liquids after the procedure, followed by a light diet. Follow-up with me in 2 weeks.
"Thanks again for involving me in the care of John, I will review them in 4 weeks."
"AI medical software was used during this consultation with patient permission."
Thank you for referring [Patient's first name and occupation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) for [review of main identified issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Issues:
1. [List gastrointestinal issues identified during the consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
2. [List other relevant medical issues in descending order of importance] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Medication List:
[List all current medications separated by commas] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Recommendations:
1. [List recommendation for management or further investigations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
2. [Additional recommendations if applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Consultation Summary:
[Summarise reasons for consultation, including specific gastrointestinal concerns or symptoms such as abdominal pain, dyspepsia, changes in bowel habits, GI bleeding, jaundice etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Document detailed history of presenting complaints including duration, severity, aggravating/alleviating factors, associated symptoms, prior treatments and responses.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Document past medical and surgical history, especially previous GI surgeries or hospitalisations and outcomes.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Current medications, including over-the-counter items and supplements used for GI symptoms.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Social history including family history, dietary habits, tobacco, alcohol, travel, and occupation.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Known allergies including drug, food, or other relevant allergens.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Dietary history, including fibre intake, protein intake, processed foods, and relevant dietary patterns.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Examination Findings and Results:
- [Vitals] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Physical examination findings, especially abdominal exam: inspection, palpation, percussion, auscultation, hepatomegaly, splenomegaly, ascites.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Rectal examination findings, including presence of blood, masses, haemorrhoids.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Investigation results including imaging (CT, MRI, US), endoscopic findings, lab tests (LFTs, CBC, inflammatory markers).] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Intestinal Ultrasound:
[State that intestinal ultrasound was performed with patient consent] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Include probe details: XX linear and YY curved] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Detailed findings by segment including bowel wall thickness (mm), Doppler signal presence and pattern, bowel wall stratification, mesenteric hyperechogenicity, peristalsis, upstream diameter.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Colonic findings including segmental bowel diameter, contents, haustra coli presence, acoustic shadowing.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
IUS Metrics:
- [Most affected segment]
- [Max bowel wall thickness in mm]
- [Colour Doppler signal grade (0–3)]
- [Mesenteric i-fat: present/absent]
- [Bowel wall stratification: present/absent]
- [Max right colon diameter]
- [Haustra coli: present/absent]
- [Posterior acoustic shadowing: present/absent]
(Only include any of the above if explicitly mentioned in transcript or context, else omit section entirely.)
[Summary of IUS findings] (Leave a blank line to be completed manually if ultrasound is performed.)
Assessment & Plan:
[1. Gastrointestinal Issue or Condition]
- [Assessment including likely diagnosis and rationale] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Differential diagnosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Planned investigations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Medical treatment plan: medication, dose, expected outcomes, side effects] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Lifestyle advice: diet, alcohol/tobacco cessation, physical activity] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Planned follow-up timeline and purpose] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Referrals made or planned] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[2. Additional GI Issue or Condition]
- [Repeat above structure as needed for additional conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Additional Notes:]
- [Patient education provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Symptom monitoring advice and warning signs to seek urgent care] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Any patient or family concerns discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Endoscopy Plan:
Pre-Procedure Instructions:
[Dietary, medication and prep instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Procedure Details:
[Type of endoscopy, date/time, location] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Consent:
[Details of informed consent process including risks discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Post-Procedure Care:
[Diet/activity instructions, follow-up timeline] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
"Thanks again for involving me in the care of [Patient's first name], I will review them in [follow-up timeframe]." (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
"AI medical software was used during this consultation with patient permission."
(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 included 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.) (Always refer to the patient by their first name, never "the patient".)
