Gastroenterology Clinic Note
Age and level of supports (iADL/ dependant ADL) 67, iADL
Occupation : Retired teacher
Reason for referral : Abdominal pain, change in bowel habits, weight loss
PMHx - Hypertension, Hyperlipidemia, Appendectomy 2005, Atorvastatin 20mg daily, Lisinopril 10mg daily
Medications - Atorvastatin 20mg, Lisinopril 10mg, Omeprazole 20mg
1. Abdominal pain
- Colonoscopy 20/10/2024 showed mild diverticulosis. CT Abdomen 25/10/2024 showed no acute findings.
Change in bowel habits
- Stool sample 27/10/2024 negative for blood and parasites.
On review/
- Patient reports intermittent abdominal pain, mostly in the lower left quadrant. Reports alternating constipation and diarrhoea. States he has lost 5kg in the last 3 months. No nausea or vomiting.
- BP 130/80, HR 78, Abdomen soft, non-tender, mild tenderness in the LLQ. Bowel sounds present.
Impression/
- Irritable bowel syndrome, Diverticular disease, possible malignancy.
Plan/
- Repeat colonoscopy in 6 months. Consider further blood tests including CEA if symptoms persist.
- Increase fibre intake. Consider a trial of antispasmodics. Discuss lifestyle modifications.
- Refer to dietician for dietary advice.
Gastroenterology Clinic Note
Age and level of supports (iADL/ dependant ADL) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Do not mention "Age and level of supports (iADL/ dependant ADL)" - just type his age and the level of supports here please Occupation : (Only insert this if mentioned during the history, otherwise omit the entire line on occupation please)
Reason for referral : (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely), list in a single row separated by comma
PMHx - [Past medical history, previous surgeries, medications, relevant to issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely), list in a single row separated by comma
Medications - List medications in a single row separated by comma
1. Issue, problem or request 1] (include issue, request or condition name only)
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[2. Issue, problem or request 2] (include issue, request or condition name only)
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On review/
- [Subjective findings, symptoms and complains] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Place all of patients symptoms here and not into the issue list)
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Impression/
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Plan/
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- [Relevant referrals for all issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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