GI Consult - General patient telehealth

Date: [insert date] 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: [Patient name, age, gender, and referring clinician] [Current issues, reasons for visit, discussion topics, history of presenting complaints] (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/alleviating factors, associated symptoms, bowel habits, previous treatments, and responses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Prior treatments, diets, and medications used for the problem] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PAST GI HISTORY: [Gastrointestinal medical 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: [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: [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: [Allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) FAMILY HISTORY: [Family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SOCIAL HISTORY: [Social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Smoking, alcohol, and substance use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Employment or work performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PHYSICAL EXAM: Deferred as consultation done over telemedicine. 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] (Include only if explicitly mentioned; 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 for multidisciplinary care or further evaluation] (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.) (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.)